The original search yielded 5777 articles: PubMed (111), PyschInfo (408), Scopus (2000), CINAHL (1253) and Web of Science (2005). Of these, 5761references were excluded either due to inappropriate outcome evaluation and/or inadequate study design or population. Sixteen references were included for full-text screening. Citation tracking and hand searching of the 16 articles yielded an additional 19 titles that may be appropriate. The final screening of full texts gave a total of 15 articles that met the inclusion criteria (figure 1). The last search was done in July 2021 with the goal of identifying new articles that may have been published since the initial database search. This led to the identification of two additional articles that met the inclusion criteria.
The following diseases were covered in the articles: Ebola Virus Disease, Methicillin-Resistant Staphylococcus aureus, Sever Acute Respiratory Syndrome, COVID-19, Middle-Eastern Respiratory Syndrome and Influenza. The articles reported studies conducted in Canada, the Democratic Republic of Congo, Hong Kong, Iran, Mainland China, Singapore, South Korea, Sweden, Taiwan, the United States and Israel. Some of these studies were multi country studies (Table 1).
The themes that emerged from the analysis can be grouped into five categories: Emotional and psychological dimensions of Q&I during a PHE; reasons for compliance with Q&I measures; reasons for non-compliance with Q&I measures; measures that could make Q&I more socially acceptable; and life after Q&I (Table 2).
Emotional and psychological dimensions of quarantine/isolation during a PHE
The first theme that emerged from our analysis was a view of the personal challenges that arose from the application of Q&I measures during a PHE. These were not explicitly referred to as ‘barriers to compliance’ to Q&I measures, but offered an insight into the individual emotional and psychological experience of Q&I. .
Five studies reported that individuals facing quarantine had feelings of frustration after having been exposed to an infected individual (Cava et al., 2005a, DiGiovanni et al., 2004, Dodgson et al., 2010, Pellecchia, 2017). This was mainly due to fears that they will be blamed by family members, colleagues or the general public for having, and possibly spreading, the disease.
You don’t know if you’re going to be blamed. There’s so much unknown … personally, from a social aspect, from a wellness, illness perspective. It just affects you, and it’s very … it’s unknown, but it’s also just you (Cava et al., 2005a).
Thus, when they received information that they were to be quarantined, they immediately panicked and experienced guilt and shame. This guilt and shame can be both an inhibitor to compliance and a disincentive to testing as individuals may wish to avoid this guilt by not taking a test.
In some cases, guilt and fear was exacerbated by a perception that Q&I was a punishment. This was partly informed by media coverage of Q&I during epidemics, which shaped how quarantine was conceptualised by the public (DiGiovanni et al., 2004, Pellecchia, 2017, Skyman et al., 2010, Barratt et al., 2010).
It seemed from reading international media reports that putting people into quarantine was the only means of cutting the transmission of the virus, yet Montserrado’s citizens were not witnessing a decrease in the number of Ebola cases: on the contrary, cases continued to be identiﬁed despite the harsh measures taken, and the perception of being quarantined as a means of punishment fed people’s already growing fears (Pellecchia, 2017)
In other cases when Q&I was considered important,study participants mentioned that they felt like they were in prison and “stuck away”, and that their independence was restricted as they had to rely on others for basic daily activities like taking a shower or having a drink (Barratt et al., 2010, Jacobs, 2007). This lack of freedom and independence, along with prevalent media coverage projecting Q&I as a punishment for spreading disease, exacerbated the guilt and shame, making Q&I less tolerable.
A third challenge to the social acceptability of Q&I is the fear of boredom. This is worse if individuals have to leave their homes and isolate in designated facilities (Barratt et al., 2010, DiGiovanni et al., 2004, Skyman et al., 2010, Blendon et al., 2006). Boredom mainly stemmed from not being able to communicate with other persons, have social visits from family members, or have access to electronic entertainment and e-communication facilities such as phones, email and so on. (DiGiovanni et al., 2004, Barratt et al., 2010). In some studies, participants reported that the size of physical space available to them in the isolation facilities made the Q&I experience unpleasant and less acceptable (Skyman et al., 2010, Barratt et al., 2010).
It was difﬁcult. I was isolated and locked in a room with double dividing walls and I did not get to go out, so it was boring. It was so dull, because they only came when they were going to clean or bring food. It was beautiful to look out onto the ﬁeld and the greenery. (Skyman et al., 2010).
However in some cases, particularly where participants were provided private rooms, they mentioned that although quarantine may have reduced their opportuinity to socialize, it afforded some degree of privacy and solace that was valued at the time. (Barratt et al., 2010). There were also diverse views on the preference for home-quarantine to address the concerns about boredom or lack of socialisation and balance this with the concerns about infecting others. (Blendon et al., 2006, DiGiovanni et al., 2004, Orset, 2018).
Finally, the attitudes and practices of staff (both health and non-healthcare staff) at Q&I facilities may also impact the acceptability of Q&I (Barratt et al., 2010, Skyman et al., 2010). Specific practices such as the wearing of gowns and gloves when interacting with patients, staff refusing to shake hands or be in close contact with patients could lead to patients feeling unclean or contagious (Barratt et al., 2010, Skyman et al., 2010). While the use of personal protective equipment (PPE) is required to limit the spread of the disease, the physical barrier that PPE creates also introduces a social barrier which can compromise the quality of care received by persons in Q&I (Barratt et al., 2010).
Reasons for compliance with quarantine/isolation measures
The reasons cited for respecting Q&I rules can be grouped into two categories:internal and external. The internal reasons were the perceptions that it was a ‘civic duty’ to quarantine if infected (DiGiovanni et al., 2004, Cava et al., 2005b), as one participant explained: “We’re all trying to be good citizens. And we’re all trying to help, you know, other people by making sacrifices like being in quarantine.” (Cava et al., 2005b) A related reason was the idea of not wanting to spread the infection to loved ones. (Jacobs, 2007).
External reasons for complying to Q&I measures were further categorised into two; first, more coercive measures including fines, identified during active monitoring for compliance by health authorities or designees (Cava et al., 2005b, Cava et al., 2005a, DiGiovanni et al., 2004, Blendon et al., 2006). The second, external reason included access to supportive servuces like assured access to professional medical care/supplies and social services such as babysitting (Orset, 2018, Pellecchia, 2017, Jacobs, 2007), access to basic needs such as groceries (Bodas and Peleg, 2020b, DiGiovanni et al., 2004, Jacobs, 2007, Cava et al., 2005a, Kpanake et al., 2019) and compensation for loss of income during the period of quarantine/isolation. Assurance that persons in Q&I will continue to receive their income, either through non-suspension of salaries or the implementation of a government compensation plan for lost wages (Blendon et al., 2006, Bodas and Peleg, 2020b, DiGiovanni et al., 2004) were the most prevalent supportive measures identified. Assurances of compensation for lost income was particularly important for individuals in part-time or casual work and for those who were self-employed (DiGiovanni et al., 2004). Willingness to comply with Q&A differed based on by individual characteristics such as age, income, household composition, professional group, perceived high risk of disease transmission and the conditions of home confinement (Orset, 2018, Bodas and Peleg, 2020b, Kpanake et al., 2019).
Reasons for non-compliance with quarantine or isolation measures
Reasons for non-compliance to Q&I measures can be grouped into five categories: perception of risk of transmission (Cava et al., 2005b, Mutombo et al., 2019, Pellecchia, 2017); lack of access to social amenities (DiGiovanni et al., 2004, Pellecchia, 2017); lack of trust in the public health system (Cava et al., 2005b, Pellecchia, 2017); lack of credibility of information from the public health authorities (Cava et al., 2005b); and inconsistency on the application of quarantine measures across jurisdictions (DiGiovanni et al., 2004, Pellecchia, 2017). These different factors were often interlinked. For example, lack of credibility or inconsistency in information, as well as differences in application of quarantine regulations could lead to breakdown of trust in the public health system making the public not to follow public health advice on Q&I.
That’s why I didn’t even ... need public health ... I could probably tell them, you know, I knew more information than they did ... I would listen to my dad more than the public health (department). It was kind of weird because they told us that I had to be quarantined. But it didn’t make sense because my roommate didn’t have to be quarantined as well because ... if I had the virus then most likely she had it as well. So it would only make sense to quarantine both of us, but I’m not sure what went on there.(Cava et al., 2005b) Emphasis added
Not only does this quote show a lack of trust – “I would listen to my dad more than the public health (department)” – but also highlighted that an inconsistency in the application of rules eroded trust further.
Past experiences (either personally or of a family member) of poor Q&I conditions also led to increased mistrust in the public health system. Some participants explained how they were at greater risk of contracting an infection while they were in quarantine because they were not provided with basic personal protective equipment such as face masks (Cava et al., 2005b). In some cases, Poor Q&I conditions were a disincentive for the general population to report symptoms to public health officials because of the fear of being held in poor conditions. A participant described how the conditions during quarantine “killed” her mother.
“I hated my mother's quarantine. It was a bad practice. People always get sick and we do not take them to the ECC. They kept my mother for 3 days and then they killed her. My father already died two weeks before, it was me who touched him and washed his clothes when he was sick. I did not get vaccinated but I’m still alive 3 months later.” (Mutombo et al., 2019).
Also, poor access to social amenities, lack of basic needs (DiGiovanni et al., 2004, Pellecchia, 2017) and infrequent heath checks by public health officials (Orset, 2018, Pellecchia, 2017) can lead to the decrease in compliance. For example:
An elderly woman in the village was mother to a young woman who had died of Ebola ten days earlier. She had been taking care of her daughter and her two children, so the authorities put all of them under quarantine in the same house. The old woman was helped by community members who provided her with food, water and ﬁrewood. From the beginning of her quarantine period, she only received two visits from the [Ministry of Health] staﬀ member who was in charge of checking her temperature and received no support at all from other NGOs in terms of food. During her quarantine, her son-in-law came to visit and attempted to take the children away with him. The man was supposed to be in quarantine himself, but he was reported to have paid a bribe in order to be released. (Pellecchia, 2017)
Here, the inability of health authorities to provide suitable amenities for Q&I led to all members of the household being held in Q&I in the same house thereby increasing their risk of contracting Ebola. Second, limited support from the Ministry of Health and other non-governmental organisations meant that community members had to step in, increasing the risk to community members. Third, this lack of support led to the son-in-law breaking his own quarantine, thereby endangering the community.
Improving acceptability of quarantine and isolation
Key approaches of making Q&I more socially acceptable were linked to the different reasons for (non-)compliance to Q&I measures. For example, in some studies, participants suggested that feelings of abandonment and boredom could be remedied by ensuring that persons in Q&I had access to communication systems (email, telephone, intranets or private internet chat rooms) which enable them to reach out to family members and healthcare workers (Barratt et al., 2010, DiGiovanni et al., 2004, Blendon et al., 2006). Despit being in quarantine, there was an expressed interest to be in physical contac with family members and friends through social visits (Barratt et al., 2010, Cava et al., 2005b, Pellecchia, 2017). Social visits from family members, community leaders, religious leaders and neighbours were considered important to reassure those in Q&I that they are not alone. (Pellecchia, 2017) Amongst adolescensts, access to study materials and e-entertainment was important for adolescents (DiGiovanni et al., 2004).
Secondly, compliance and social acceptability of Q&I can be improved if persons were financially compensated or given paid leave during the time they are in Q&I. (Blendon et al., 2006, Bodas and Peleg, 2020b, DiGiovanni et al., 2004). This was particularly relevant for persons working in the informal sector as quarantine could have a negative impact on their household income. (Pellecchia, 2017). In cases where articipants were financially compensated, there were no reports of financial hardship although they reported that the process of compensation was slower and could be improved (Cava et al., 2005a).
Life after quarantine and isolation
Post-quarantine and isolation experiences had an impact on public perceptions about Q&I during epidemics (Table 2). Stigma and discrimination were common experiences (Cava et al., 2005a, DiGiovanni et al., 2004, Blendon et al., 2006). Persons who had been in Q&I received unwanted attention, ridicule, avoidance, and withdrawn invitations from social events. This made it difficult to re-establish social relationships.
There’s a couple of girls there I go to lunch with daily. When I came back it was like ~Hi.~ One of them didn’t talk to me for about 3 days. Wouldn’t look at me .... and it’s like [tentatively] ~Hi.~ . . . Stayed away. Stayed very far from me .... and didn’t have lunch with me. They did not have lunch with me for a long time (Cava et al., 2005a)
Sometimes the stigma and discrimination could go on for weeks after the end of the quarantine period, This could be extended to family members, such as children and spouses (DiGiovanni et al., 2004).
Despite these negative implications, positive impacts of Q&I were also reported (Wang et al., 2011, Cava et al., 2005b). For example Q&I offered an opportunity to become more conscious of public health measures, such as hand hygiene and avoiding crowded spaces during a PHE (Cava et al., 2005b); teach others about impacts and coping mechanisms