By Howard White, CEO
Blog series: Responding to coronavirus: evidence from Campbell reviews, Part 1
The coronavirus pandemic is amongst the largest public health challenges faced by the world in recent decades. It will have profound consequences for all countries in the coming weeks and months, and possibly years.
This is the first article in a blog series presenting evidence from Campbell maps and reviews to help inform national policy and individual practice during this time. This article is focused on the immediate response. Future articles, to be published next week, will look at economic and social interventions to deal with the effects of the virus.
Mapping the evidence base
Understanding the virus is key to the policy response. To synthesise the evidence, we first need to identify the relevant evidence.
Part of the response of the global Campbell network to coronavirus is the work of Dr Ciara Keenan of Campbell UK & Ireland in producing a map and supporting database of Covid-19 research. This a crowd-sourced project, which has benefitted from screening and coding support from the Campbell China Network to capture the growing body of Chinese research. Many research teams are using the Campbell UK & Ireland research database to conduct evidence synthesis.
Washing your hands to prevent the spread of the virus
Governments around the world are encouraging frequent handwashing as a way of stopping the spread of the virus. But historically, as documented in the Campbell review on promoting better hygiene practices and improved sanitation, it has been difficult to achieve sustained behaviour change in this area.
What approaches have been most effective? The review finds that community-based approaches show the most consistent impact. But these approaches may be inconsistent with social distancing. Of more immediate relevance is sanitation and hygiene messaging which may be communicated through TV, radio, traditional media and social media. Messaging can increase handwashing with soap, though the effect does not seem to be sustained. In the current environment in which people are likely receptive to advice, messaging which focus on both the importance of handwashing and how to wash hands – that is with soap and for at least 40 seconds – should be widely adopted.
Once the crisis is over, community-based approaches for handwashing and other hygiene practices should be rolled out to sustain these practices, given their proven benefits.
Supporting frontline health worker knowledge and practice
As knowledge about the virus and how to deal with it spreads, it is important to ensure that frontline health workers are aware of and adopting good practice. The Campbell review of e‐learning of evidence‐based health care (EBHC) by healthcare professionals shows that e-learning is better than no learning – and as good as face-to-face learning – in improving knowledge and skills. But there is no impact on attitude and behaviour. Attitude and behaviour are only improved by blended learning, which combines e-learning with face-to-face learning.
Traditional class-based face-to-face learning is not compatible with social distancing. Health agencies can adopt e-learning to disseminate information about good practice relevant to coronavirus. But further research, which can be built into new programmes, is needed on using more interactive material, or online face-to-face meetings, in place of traditional classroom teaching to achieve the impact on attitude and behaviour.
Helping those hit by the crisis: cash transfers
Many countries are adopting cash transfers to households suffering a loss of income as a result of the crisis. In developed countries this policy has taken the approach of subsidizing firms to continue to pay their workers even if they are not currently working. Denmark was one of the first countries to go this route, with government paying 75% of the wage bill.
This approach has raised questions about the self-employed. Similarly, in developing countries, the question arises of how to reach the substantial numbers in the informal sector, and those living in rural areas who depend on household production for their survival.
The Campbell review on cash transfers in humanitarian settings is relevant to these discussions. The review compares the costs and effectiveness of different modalities of delivering different types of support: cash, vouchers or in-kind.
The most immediate relevant insight from the review is the need to assess and use existing systems of cash delivery. Is mobile money common and do most intended beneficiaries have mobile phones, as is the case in East Africa? Is there an existing cash transfer, micro-finance or other social programme which may be used to transfer the cash? Analogously, many countries have a system of determining eligibility for anti-poverty programmes, such as the Below Poverty Line (BPL) cards issued to households in India, which can help rapid identification of those most in need; although BPL cards are criticized as being poorly targeted.
The second key insight from the review is to consider the transaction costs of different delivery mechanisms, from the point of view of both the provider and the beneficiary. For coronavirus, an additional consideration is to develop approaches consistent with social distancing. These costs depend on the contextual factors mentioned above. Mobile transfers have low variables costs, but a large fixed, start-up cost especially is such a system is not already in place. Providing vouchers rather than cash or food, especially restricted vouchers, is similarly costly to set up. On the other hand, cash transfers typically require the recipient to travel somewhere to collect the transfer, which may not be desirable or possible under movement restrictions.
Hence, deciding the appropriate distribution system needs to be done on a case-by-case basis for each country. National governments should determine the most appropriate means of distributing cash or other support, and international agencies should provide support through those channels rather than create parallel systems.
The risks of releasing prisoners
Any situation which brings a large number of people into regular contact is an environment in which coronavirus can easily spread. Last week in the UK there was a 20% increase in recorded cases in 38 prisons. A Reuters survey of US prisons and jails showed the growing threat to their inmates. The easiest policy response is early release, most likely with those released being asked to stay at home possibly with electronic monitoring.
Such a response of course raises concerns about increased risk of crime. But these concerns are misplaced. A Campbell review found that non-custodial sentences are no more likely to result repeat offending than are custodial sentences.
Moreover, the risk of crime is less anyway. Many crimes are opportunistic, and as more and more families spend most their time at home opportunities are less. Data from many countries around the world show that crime rates have been falling. Crime in San Francisco is less than one-third what it has been in recent years, with falls also observed in other US cities. In Poland crime fell by 50% during March. However, the categories of crime which have risen are child abuse and intimate partner violence. In the US, domestic disturbances, which includes noise complaints and abuse, have risen by 10-30%.
Intimate partner violence and child abuse
Advocacy interventions seek to empower women who are subject to abuse, and to link them to support services. A Campbell review of these interventions finds that brief interventions are not effective in reducing physical or sexual abuse, but that more intensive interventions may work. However, the intervention may reduce depression and improve quality of life. The effectiveness of these interventions is further challenged by limited service delivery in the current environment. So, there is a need to test intensive advocacy intervention models which can be delivered remotely. And to plan for a roll-out of intensive advocacy and supporting services once the situation allows.
Where intimate partner violence does occur, it can cause lasting psychological damage to the children who witness it. Whilst the evidence base is limited, the Campbell review of the effectiveness of interventions to promote well‐being among children exposed to intimate partner violence found that programmes do work, especially if delivered in a home setting. Programmes working with the non-violent partner, usually the mother, are most effective. However, a stronger evidence-base is needed. The current environment presents an opportunity for testing delivery of courses or materials online.
With the support of UNICEF, Campbell will soon be publishing a map of interventions to reduce violence against children. There are already Campbell reviews on bullying and cyber abuse.
With schools closed, children are not exposed to the daily threat of physical encounter with bullies. But children spend more time online when they don’t have school. And many schools are delivering material online. So, the risk of cyber abuse and bullying can increase. The Campbell review finds that interventions to protect against cyber abuse increase a child’s knowledge as to what constitutes abuse but do not have an effect on risky behaviour. So, whilst this is an ideal time to present online courses to children to prevent online abuse, the opportunity needs to be taken to test different approaches to find what works to change behaviour.
Help to close the gaps in research
There is much to learn from systematic reviews, which provide the most reliable guide to policy. However, there remain many gaps. If you would like to contribute – financially or as a researcher – to Campbell’s Covid-19 response, or more generally to our vision of ‘better evidence for a better world’, please get in touch: info@campbellcollaboration.org.
Future blog posts will present findings from Campbell reviews on policies and programmes for the social and economic response to the medium- to long-term consequences of the Covid-19 pandemic.