Quarantine and isolation capability in a rapidly changing environment
Given the rapidly changing environment in which community members were being asked to quarantine or isolate, participants all reported a need for the provision of a single, trusted information source which explained the responsibilities and rights of people undertaking quarantine or isolation and the latest information on the disease in accessible language. This is illustrated by a participant who said:
“There’s so much information, what do you trust and what do you believe?” (ID3)
Participants expressed confusion relating to their rights to exercise outside their property, navigating share-house environments, their risk of transmitting the virus to others and access to strategies to maintain wellbeing throughout the experience, as one participant explained:
“…I had been given information even if it was a website that said “if you are in self-isolation, this is what it means”. I needed to know explicitly whether I was allowed outside or not. I needed to know what the consequences were if I chose to break the rules, I needed to know how I got access to food and essential medicines if I was on my own. It would have been helpful to have tips on your mental wellbeing when you are stuck at home on how to keep yourself physically active.” (ID9)
Information overload and mixed messaging forced participants to switch off or turn away from available information and they felt alone in interpreting their ideas about how to quarantine or isolate given their individual circumstances. Circumstances which influenced the type of information required included living environment, language and cultural backgrounds, health needs (including for diagnosed cases, pregnant and post-partum women), family circumstance, access to social supports, mental health issues and employment.
Toward the end of the quarantine period, many participants who were not experiencing symptoms described balancing fluctuating motivation to remain quarantined due to loneliness and anxiety. This was clearly expressed by a participant who explained:
“I was thinking… in the second week, if I was fine, I might move to a friend’s house and continue self-isolation there…. Like I’m obviously trying to do the right thing, but it’s just based on my judgement. But if there was a way for me to be like “Hey I’m thinking, I wouldn’t mind going for a run at 6am in the morning, is this appropriate to do in self-isolation?” I don’t know where you direct those questions…” (ID1)
Given potential impacts on mental health, community members may require alternative strategies to relieve negative impacts of the experience as well as information about transmission risk relevant to each day of quarantine or isolation for those seeking to rationalise decisions.
Belief in efficacy and ability to impact the control of pandemic
Despite the relatively small number of cases in Australia in the early stages of the pandemic, participants expressed a high level of concern about the seriousness of COVID-19 and a belief in the importance of quarantine or isolation to reduce transmission. When deciding to quarantine, many factored in their perception of risk to themselves and the risk to loved ones, as this participant stated:
“it was quite a small chance of us having the virus but we know that this is the right thing to do to not expose my in-laws to this” (ID2)
Risk perception in terms of concern about the seriousness of the disease and belief in the efficacy of quarantine to reduce transmission were both motivating factors. However, many participants were demotivated by a perception that the impact of their personal efforts may be undermined by others’ actions or that they had limited ability to influence pandemic control outcomes, as expressed by participants below who suggested:
“It’s just really frustrating to see … we live on a main road and the traffic on that road hasn’t decreased since I’ve been home at all, I can still tell people are going out, people are congregating.” (ID25)
“you’ve got these professional footballers that had a god damn party on Saturday night…, I’m frustrated the AFL even went ahead because that was pretty spineless move for them to do that and risk the player’s welfare. And just to shit the example for the rest of the country like ‘oh sport can go ahead, and I can go out partying’ or whatever.” (ID3)
Many participants expressed a sense of social responsibility and self-efficacy during quarantine or isolation but were concerned about the overall efficacy in the context of others. This was described in terms of government, community and individual behaviours and across several different contexts. This illustrates a need to recognise the intersection of individual belief in efficacy and the influence of external factors on motivation when seeking to enhance adherence with isolation and quarantine.
Judgement, fear and stigma
Community stigma and judgmental tone in public messaging impacted on both the motivation and opportunity for participants to quarantine as well as on their mental health. This was experienced because of public messaging about individual responsibility to “do the right thing” despite significant structural barriers that community members encountered.
“… bigger problem is this tone of the information is like, this angry parent… ‘you must do this, if you do this you will be fined’…There’s no messaging that’s like… ‘Hey this is actually something that’s really tough to do, here’s how [to do it]’… it assumes that I’m going to break the rules and like, we’ll get you if you do and…you’re a bad person.” (sic) (ID1)
Participants from Asian backgrounds experienced stigma and discrimination due to racism. This occurred for adults and children and the experiences made participants less likely to want to disclose their quarantine status to employers, peers or other community members. Some were also fearful about their re-entry into the community after the period of quarantine or isolation. The experience of racism is described by two participants below:
“she is 10 years old and…the kind of things people at school were saying to her when she came back, like “Chinese people bring the virus to Australia” ...I don’t want to use serious or strong language, but …you know just like that white people are against Asian people who wear the masks….” (sic) (ID21)
“my boss never said anything about not being allowed to take sick days, but I guess it’s that sense of I’m not contributing. I also wonder if … because I’m Asian as well and there’s been a lot of racism against Asians since the virus started spreading.” (ID19)
Stigma due to positive diagnosis was experienced by a range of participants from non-migrant backgrounds due to fear, misinformation or lack of information about re-entry into the community after a positive diagnosis. Some employers and community members had requested doctors’ certificates from people who had completed a 14-day quarantine without symptoms which, at this time during the early stages of the pandemic, was not required.
Active provision of services as a practical and symbolic message of shared responsibility
In general, participants identified a lack of support services as a barrier to following guidelines. While many were able to rely on family and friends to help them, the gap was described as a “fend for yourself but stay away from others situation” (ID13) and many were uncomfortable with being a “burden” or questioned the reasonable expectations that they could place on family and friends to provide for them.
“if everyone’s going into lockdown…like what’s a reasonable expectation for people to support me as well?” (ID1)
“Basically we were left to our own devices,…we just had to Google it and kind of look it up ourselves, no one has been in contact with us in terms of being isolated … no government agency or anyone has actually asked us….” (ID21)
Participants were highly aware of the changing pandemic response measures and community reaction to them. There was a heightened sense that they were alone to manage often challenging structural issues that impacted on both their opportunity to quarantine or isolate effectively and their motivation due to mental health impacts as expressed by a participant who stated:
“It’s a huge difference between feeling like you are doing a specific duty to protect people, as opposed to being thrown in a locker and throwing away the key and there’s been no way to…move forward… it’s just the discomfort you have to sit with for a few weeks and there are very few ways to let it out and keep distancing, it’s hard to live. I’ve never felt so disconnected before” (ID24)
A few participants who, despite understanding the purpose and importance of quarantine and being highly motivated to adhere to these restrictions, reported that they “broke quarantine” because they needed to access food and income support. After unsuccessfully trying to access federal government income support via phone, a few participants left quarantine to attend the support office, while others collected food and medicines from local shops as described by this participant who said:
“I went to the local supermarket probably in breach of my personal and government rules … I went down there specifically to check what was happening with availability of things…then I went to the chemist shop and got a month’s supply of my medications and checked them for hand sanitizer and medicated soap and they were out of them, so that way I informed myself about what the situation was in that regard.” (ID7)
While access to food and essential services can provide community members with the opportunity to follow guidelines, the symbolic offer of services may also enhance a sense of shared responsibility for people participating in quarantine and isolation, thereby increasing motivation.
Physical environment that promotes mental and physical health and wellbeing
A critical enabler of quarantine and isolation was identified as the physical environment in which people were residing. People with access to their own house with a garden, pets and ability to access outdoor space had significantly less concern about their mental health and their ability to stay at home for the required amount of time.
“I’ve got a road bike that I’ve put on a wind trainer in my garage… I’ve got a backyard so that’s great, so I’m just throwing a ball around and playing with him [dog]…. I’ve been gardening, …I know that I’ve got people looking out for me and getting good fresh fruit and vegetables, I’ve got a yard to be out in the sunshine and to be able to get outside.” (ID10)
“…having a good view. I look out to a park which is very good for my morale rather than just a brick wall, which I think could be quite maddening. Just to have some sort of window view where you can see some greenery or nature because it is quite soothing.” (ID18)
Conversely, people with less control over their environment and the ability to access communal spaces and outside areas reported higher mental health impacts affecting their motivation and opportunity to continue to quarantine as described by a participant who said:
“I have a room to myself and basically I have been staying in the room. I eat on a separate table, which is two meters apart. [We are] keeping our distance in the assumption that I have it, which is quite effective for a while, but you know after a while it actually does your head in a bit…. As the days have gone on, I’ve got yet more uncomfortable with the quarantine and you feel you should have had symptoms some time ago, so you become a bit more lax over time (sic)” (ID24)
The physical environment in which people were undertaking their period of isolation or quarantine had a significant influence on their opportunity to follow guidelines. This indicates that supporting people by providing a more conducive physical environment may improve adherence with these public health requirements.
The need for emotional support in a time of uncertainty
The unchartered nature of their situation and ongoing uncertainty about the future had a significant effect on people’s mental health and wellbeing during quarantine and isolation. The feeling of social isolation left many feeling lonely, disconnected and concerned about family members and those less fortunate in the community. Uncertainty around their immediate future created a source of stress and anxiety for many. Many participants were unsure if authorities knew about their situation and expressed that they would have liked to have had someone check in on them, as described by two participants who stated:
“…No one checked on us whether or not we needed any support. It all 100% relied on our family in Melbourne and friends.” (ID2)
“I don’t know the feasibility of it, but just like a check in phone call of someone just sort of just seeing that you’re alright. Or like, ‘what do you need?’ Would’ve been really helpful.” (ID1)
Many participants identified the desire and need to talk to someone about their difficulties but were unfamiliar with available mental health support services and had little experience accessing them, as one participant stated:
“I haven’t really seen anything advertising psychological support for people. What if you already suffer from anxiety or depression and you suddenly have to isolate and you know, what if you are having a really bad panic attack or anxiety attack, who’s going to help you then, that’s a worry, so I think more information around supportive services around mental health is important, because that’s going to be what forces people to go outside of isolation” (ID10)
“…Your mental state does get impact(ed) by this, if you’re not a strong person it can be quite a lot…” (ID18)
In the face of few formal support services available, many people sought and utilised their own informal support networks as seen by friends and family members dropping off necessities such as groceries and medications. Several participants also spoke about the emotional support they received by joining online community groups to share their experiences, ask questions and receive and provide offers of assistance, as described by two participants:
“it’s just like people posting … nice things that they do for other people or what others have done for them … people giving away toilet paper to the elderly and having that connection with them to help people out in times of like need I guess so that’s kind of nice to have that as well. It’s kind of like a positive newsfeed instead of you know, having to worry so much.” (ID20)
The need for emotional support as a way of increasing the opportunity for people to continue their isolation or quarantine highlights the importance of providing accessible mental health support services and including these in the planning process.
Planning and practicing to promote self and community efficacy
In the early stages of the pandemic in Australia, needing to quarantine or isolate was “a shock” to many participants who did not have time to plan strategies to enable this to happen. Quarantine preparedness planning is a strategy which appears to have reduced anxiety about the experience, enhanced motivation and resulted in enabling environments for a few participants. The small number of participants who had developed a plan to guide them were more positive about their ability to overcome any challenges they may face in completing quarantine or isolation. These few participants developed plans which included; how to interact with others in the household, who would support them with groceries and essential items like medication and strategies for maintaining physical and mental health in their context. This was exemplified by one participant who stated:
“…working out strategies in conversations with my house mate on the phone and letting him talk about anything…I then sent emails about “these are the things we need to do”, because we each had our own bedroom, our own living room, we had the shared spaces, so I kind of worked it out at a point by point, hoping that it would work in practice….So I think for us having a plan …” (ID5)
Many people expressed a desire for clearer information about their circumstances and an indication of what they can anticipate as a way of assisting with planning and allaying anxiety. In this way, information acts as a form of emotional support by providing reassurance and practical assistance and can reinforce the opportunity to remain in isolation or quarantine. This was described by two participants who stated:
“…there was no preparation, we were kind of thrown in and then like, “okay, that’s it you are not allowed to go anywhere. You have to figure everything else out for yourself”. (ID20)
“I think that it took me by surprise and that was the most difficult part. If I had been prepared for it, I felt that it would have been better…” (ID19)
A lack of planning among participants (and government) impacted on their capability, motivation and opportunity to complete quarantine or isolation. It was perceived that at a community level, a lack of planning and ongoing uncertainty could result in individuals who had the desire and capacity being unable follow them.