The Economic Case for Pandemic Preparedness and Response

5. Community-based infection prevention and control measures are the first line of defence during outbreaks

Abstract

Infection prevention and control (IPC) priorities implemented in community.

settings are essential to prevent the spread of infections, including those caused by resistant organisms. This chapter reviews the existing evidence on the implementation of community-based IPC interventions, with an emphasis on 4 measures: 1) enhancing hand hygiene, 2) scaling up mask-wearing, 3) improving respiratory etiquette and 4) ensuring adequate ventilation and air filtration in indoor settings. The chapter starts by presenting findings from a new OECD survey on the landscape of community-based IPC policies implemented in 22 OECD Members and 2 accession countries. Next, the chapter presents and evaluates the existing evidence on the effectiveness of these interventions. After exploring the factors that influence the level of adherence with community-based IPC measures, the chapter concludes by exploring 9 policy options that can be used to motivate greater compliance. Throughout the chapter, best practice examples from OECD countries are provided.

In Brief

Key messages

Community-based infection prevention and control (IPC) measures provide the foundation for public health response to outbreaks in the absence of pharmaceutical interventions and vaccines

• Community-based infection prevention and control (IPC) measures refer to a set of interventions that mobilise individuals to actively participate in behaviours that can help interrupt the transmission of diseases in the community (e.g. hand hygiene, mask wearing, respiratory etiquette and indoor ventilation and air filtration).

• The COVID‑19 pandemic put a spotlight on community-based IPC measures as a crucial strategy to curb the spread of outbreaks. Today, the importance of community-based IPC measures is widely recognised but there are crucial gaps in their timely implementation. The 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community showed that:

  • All 24 OECD Members and accession countries surveyed reported promoting community-based IPC measures during COVID‑19, encouraging their use across settings such as childcare institutions, schools, workplaces and public or private buildings.

  • Among the 24 OECD Members and accession countries surveyed, most have prioritised hand hygiene and respiratory etiquette in their current pandemic preparedness and response plans (15 countries), while fewer prioritised mask-wearing (14 countries) and indoor ventilation (10 countries).

  • Interventions promoting hand hygiene are markedly more common than those focussed on mask use, respiratory etiquette or indoor ventilation and air filtration. Countries report stronger activity in educational initiatives and behavioural interventions in public spaces (e.g. visual cues). Many also involve local communities, technical experts and other stakeholders to ensure that programmes are evidence‑based and effectively implemented. By contrast, far fewer countries report distributing IPC supplies or running large‑scale awareness campaigns.

  • Only 6 of the 24 OECD Members and accession countries surveyed reported having a dedicated budget to support community-based hand hygiene and respiratory etiquette initiatives. Funding gaps are even more pronounced for mask wearing and indoor ventilation activities, with just 5 and 3 countries reporting dedicated resources respectively.

High levels of community compliance key to ensure community-based IPC measures are effective

• Emerging evidence shows that community-based IPC measures are an effective means to fight viral and bacterial infections, including resistant infections. But the magnitude of their impact depends heavily on community compliance.

• Globally, the level of compliance with community-based IPC measures remains low. The determinants of compliance are complex, reflecting situational factors (e.g. during/aftermath of outbreaks), sociodemographic characteristics, knowledge and understanding about disease transmission and the effectiveness of community-based IPC measures, spread of misinformation, risk perceptions and personal beliefs, societal norms and beliefs.

• The OECD analysis identified nine policy options that countries can consider sustaining high levels of compliance over time:

  • Provide clear regulations, guidelines and policy advice to promote best practices

  • Ensure adequate access to IPC supplies and materials (e.g. handwashing stations, masks)

  • Introduce financial incentives (e.g. financial rewards and/or penalties)

  • Design, implement and fine‑tune community-based IPC programmes that are fit to address the unique community needs

  • Improve public awareness and understanding around community-based IPC measures

  • Implement behavioural nudges to build and maintain healthy behaviours (e.g. visual reminders)

  • Ensure sustainable funding for community-based IPC programmes

  • Set up routine monitoring and evaluation mechanisms to track compliance

  • Foster trust in public institutions

5.1. A primer on community-based IPC measures: What are they and why they are important?

Community-based infection prevention and control (IPC) measures refer to a range of non-pharmaceutical interventions implemented at the community level, with the aim of preventing and controlling the spread of infections. These measures typically involve mobilising community members to actively participate in behaviours that promote health and interrupt the chain of disease transmission. The vast majority of evidence demonstrates that community-based IPC measures can minimise the adverse health and economic consequences of viral and bacterial infections (Aiello et al., 2008[1]; Suess et al., 2012[2]), as well as antibiotic resistant infections (Maillard et al., 2020[3]). During epidemics and pandemics, these measures can play a pivotal role in emergency response, especially in the absence of effective medical treatments and vaccines (Müller, Razum and Jahn, 2021[4]). If compliance rates in the community are high, these measures can further yield considerable beneficial effects on the broader economy as they would limit the need for resorting to more stringent and restrictive policies.

The COVID‑19 pandemic saw an unprecedented surge in the implementation of community-based IPC measures. Recent examples from OECD countries include hand hygiene campaigns in the United Kingdom (Department of Health and Social Care, 2020[5]); distribution of free‑of-charge face coverings and masks in France (Service-Public, 2023[6]); raising awareness around the importance of respiratory etiquette in Canada (Infection Prevention and Control Canada, nd[7]); and improving natural and mechanical ventilation practices in Australia (Government of the State of Victoria, 2023[8]). The OECD countries differed considerably in terms of how they designed and implemented these measures in the context of COVID‑19, with these differences creating a wide range in their overall effectiveness (Lison et al., 2023[9]; Persad and Pandya, 2022[10]).

Despite the benefits of community-based IPC measures, little is known in terms of: 1) the extent to which OECD countries rely on them to prevent and control various types of infections such as airborne diseases or antimicrobial resistance (AMR), 2) whether OECD countries integrate, or plan to integrate, them in their national pandemic preparedness plans, 3) the factors that influence the level of compliance with these measures in the community and 4) the policy levers that can be used to promote greater compliance in the general public. These knowledge gaps highlight the urgent need for generating high-quality evidence that can help OECD countries capitalise on the benefits of these measures.

Recognising these gaps, this chapter aims to review the existing evidence on the implementation of IPC practices in community settings.1 The analysis focusses on four measures: 1) enhancing hand hygiene, 2) improving respiratory etiquette,2 3) scaling up mask-wearing and 4) ensuring adequate ventilation and air filtration in indoor settings. These interventions were selected because they are:

• Consistent with best-practice examples and international guidelines for limiting the spread of viral and bacterial infections and AMR rates

• Relevant to the policy priorities considered in the national pandemic preparedness plans across OECD and

• Shown effective for limiting the spread of infections based on high-quality evidence.

The chapter starts by examining the landscape of community-based IPC programmes implemented in OECD during the COVID‑19 pandemic. The four measures examined in this chapter do not represent the full range of community-based IPC interventions. Others, such as environmental cleaning in community settings and waste management, also contribute to interrupting transmission (Dunn et al., 2024[11]) but fall outside the scope of this chapter. It, then, assesses the extent to which these measures have been integrated in national action plans to tackle disease outbreaks and future pandemics. Data presented in this section are gathered through the 2023‑2024 OECD Survey on Community-based IPC Measures (Box 5.1). Next, the chapter shifts its focus and reviews the existing evidence on the effectiveness of the selected IPC measures. Most evidence presented in this section comes from the OECD and European Union/European Economic Area (EU/EEA) countries, though evidence from Group of 20 (G20) countries and OECD accession countries is also discussed. Next, the chapter explores the factors that impact the level of compliance with community-based IPC measures and presents nine policy options that can be used to motivate greater compliance in the long term.

Box 5.1. The 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community

The COVID‑19 pandemic put a spotlight on community-based IPC measures as a crucial strategy to curb the spread of SARS‑CoV‑2. Despite this, comparable cross-country data on key aspects of implementing these measures have not been widely available. The 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community gathered information on 4 community-based IPC measures: i) hand hygiene, ii) respiratory etiquette, iii) mask wearing and iv) indoor ventilation.

The OECD survey had three focus areas:

i) The extent to which OECD Members and accession countries deployed community-based IPC measures during the COVID‑19 pandemic,

ii) Whether community-based IPC measures are included as part of efforts to strengthen health system resilience and to prepare for future disease outbreaks and pandemics and

iii) The strategies that countries use to promote a greater level of compliance in the general public with these measures.

The questionnaire was sent to 43 countries in October 2023 and responses from OECD Members and accession countries were accepted until January 2024. A total of 24 countries, including 22 OECD Members and 2 accession countries, provided responses. More detailed information on the countries that participated in the survey is available in Annex Table 5.A.1.

5.2. Critical gaps undermine the implementation of community-based IPC measures

5.2.1. All OECD Members and accession countries deployed all 4 community-based IPC measures as part of their COVID‑19 response

All 24 OECD Members and accession countries participated in the OECD survey indicated that they encouraged the use of all 4 of the community-based IPC measures as part of their COVID‑19 response. These measures were implemented in the gamut of community settings from childcare institutions, schools and universities, workplaces and offices, to public and private buildings and households. Specifically, the OECD survey looked at the individual interventions and found that (Figure 5.1):

• Hand hygiene: Hand hygiene was promoted widely across many community settings, including in childcare institutions, schools and universities, workplaces and public buildings and to a lesser extent in private buildings and households.

• Mask wearing: 23 out of 24 OECD Members and accession countries that participated in the OECD survey reported that they promoted mask-wearing in schools and universities, making them the most popular setting for this intervention. In 22 countries, respondents reported promoting mask wearing in other settings such as workplaces and offices, public and private buildings. Mask-wearing was also promoted in childcare institutions and households albeit to a lesser extent.

• Respiratory etiquette: Respiratory etiquette was most frequently promoted in households, workplaces and offices, followed by other community settings such as schools and universities, public and private buildings.

• Indoor ventilation: Indoor ventilation was the least frequently promoted community-based IPC measure. Most OECD Members and accession countries chose to implement programmes targeting childcare institutions, schools and universities and public buildings. Workplaces and households were targeted to a smaller extent. Private buildings received the least attention.

Figure 5.1. Community-based IPC measures were implemented in a wide range of settings during the COVID‑19 pandemic

Number of countries that reported implementing community-based IPC measures during the COVID‑19 pandemic, by community setting

Note: This graph presents the number of countries that responded to the question “What were the main settings/population groups that the IPC interventions targeted during implementation during the COVID-19 pandemic?” The list of countries that participated in the survey is provided in Annex Table 5.A.1.

Source: Country self-assessment responding to the 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community.

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5.2.2. The centrality of community-based IPC measures is widely recognised but more needs to be done to fill the gaps in implementation

During the COVID‑19 pandemic, the OECD Members and accession countries deployed a wide range of initiatives to promote greater compliance in the general public with community-based IPC interventions such as distributing free‑of-charge hand hygiene materials (e.g. hand sanitisers and face masks); mass media campaigns and educational activities targeting community members; monetary/non-monetary fines for non-compliance and behavioural interventions (e.g. visual cues and reminders) (a more detailed discussion of these initiatives is provided throughout Section 5.3. These programmes often considered the benefits to high-risk groups such as young children, older people and people living with certain medical conditions.

Today, the importance of community-based IPC measures is widely recognised in the current national action plans on pandemic preparedness, pandemic influenza or other major infectious diseases with epidemic potential of most OECD Members and accession countries which participated in the OECD survey, but there are gaps (Figure 5.2).The survey shows that 15 out of 24 OECD Members and accession countries indicated that they have already incorporated improving hand hygiene and respiratory etiquette as a priority in their action plans and 14 countries included mask-wearing as a priority. In contrast, improving indoor ventilation practices is not widely prioritised, with only 10 countries reporting that this intervention is incorporated in their national pandemic preparedness plans.

Figure 5.2. Community-based IPC measures highlighted in national pandemic preparedness plans, by intervention

Number of countries that reported having current national action plans on pandemic preparedness, pandemic influenza or other major infectious diseases that refer to community-based IPC measures

Note: This graph presents the number of countries that responded to the questions “Does your country’s current national action plan(s) on pandemic preparedness, pandemic influenza or other major infectious diseases with epidemic potential refer specifically to hand hygiene/mask-wearing/respiratory etiquette/indoor ventilation?” The list of countries that participated in the survey is provided in Annex Table 5.A.1.

Source: Country self-assessment responding to the 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community.

The majority of OECD Members and accession countries that already refer to community-based IPC measures in their current national action plans reported that they plan to continue to incorporate these measures in their future plans. In addition, 3 out of 4 OECD Members and accession countries that do not currently refer to at least one of the community-based IPC measures report that they plan to include at least one of these measures in their next national pandemic preparedness plans, suggesting that the importance of these measures to tackle infectious diseases is widely recognised. For example, in Luxembourg, this work is being co‑ordinated by the Emergency Preparedness and Response Service for the development of the health preparedness and response plan.

Despite this, as shown in Figure 5.3, more needs to be done to fill crucial gaps in the implementation of these measures (Annex Table 5.B.1 provides a dashboard that provides more detailed information on the state of implementation of policies to promote community-based IPC practices). A closer look at the OECD survey shows that:

• Distribution of IPC supplies: Only 5 out of 24 OECD Members and accession countries reported that they have programmes that distribute free‑of-charge hand hygiene materials (e.g. hand sanitisers) and 3 countries reported having arrangements for distributing free‑of-charge facemasks. Only 1 country reported having programmes to improve the accessibility of air filters to improve indoor ventilation through the distribution of free‑of-charge air filters.

• Mass media campaigns: Only 5 out of 24 countries participating in the OECD survey reported that mass media campaigns for hand hygiene promotion achieved the highest level of implementation, which entails having national-level activities/programmes that are fine‑tuned/modified based on regular monitoring and evaluation activities. There are also gaps in the implementation of mass media campaigns promoting mask wearing and respiratory etiquette, with only 2 and 3 countries reporting to have mass media campaigns implemented at the most advanced for these interventions, respectively.

• Strategies for increasing access to accurate information: Information-based strategies are widely used by OECD Members and accession countries to increase awareness and understanding around community-based IPC practices. However, there are notable gaps. For example, 13 out of 24 countries reported that they have educational activities targeting community members to improve hand hygiene practices, but similar programmes only exist in 8 countries for promoting respiratory etiquette and in 6 countries for promoting mask wearing. There is also room for improving access to accurate information by offering free‑of-charge phone lines and publicly available websites that offer high-quality public health information.

• Behavioural interventions: Many OECD Members and accession countries deploy visual cues in public areas and send text reminders to motivate greater compliance with community-based IPC practices but there are gaps. For example, 15 out of 24 countries that participated in the OECD survey indicated that they use visual cues in public areas as a reminder of best practices in hand hygiene and respiratory etiquette, whereas only 8 countries use visual cues for promoting mask wearing.

• Engagement with relevant stakeholders and empowering local communities: Engagement with relevant stakeholders and local communities can be improved. Of the 24 countries surveyed, 12 reported that they currently have advanced level arrangements for engaging relevant stakeholders and local communities in the design and implementation of programmes to improve hand hygiene and 8 countries have similar arrangements for respiratory etiquette. These figures are lower for other interventions.

• Involving independent experts, scientists and credible public figures: 10 out of 24 countries indicated that they currently have advanced level arrangements to involve independent experts, scientists and credible public figures to muster greater public compliance with respiratory etiquette and 9 countries have similar arrangements for hand hygiene. This strategy is also used to promote better respiratory etiquette and indoor ventilation but to a smaller extent.

Figure 5.3. OECD Members and accession countries can do more to promote community-based IPC programmes

Percentage of countries that reported having activities to promote greater compliance with community-based IPC measures, by level of policy implementation

Note: This graph presents the number of countries that responded to the questions “What type of policies does your country currently implement to address the factors that may hinder the general public’s willingness to comply with hand hygiene/mask wearing/respiratory etiquette/indoor ventilation in the community?” Free handwashing materials: Distribution of free‑of-charge handwashing materials (e.g. hand sanitisers); Mass media campaigns: Organising mass media campaigns (e.g. public announcements in TV/radio); Educational activities: Educational activities in the community such as peer-training, web-based training; Information materials: Distribution of free‑of-charge informational materials; Visual cues: posters, stickers in highly visible areas; Phone lines/websites: Free‑of-charge phone lines/websites to provide accurate public health information on best practices; Involve experts and others: Involve independent experts, scientists and credible public figures while communicating with the general public. Levels of implementation include: No implementation: No plans for implementation; 1st level = Activities/programmes were implemented at the regional/sub-national level; 2nd level: Activities/programmes were implemented at the national level; Most advanced level: Implementation of activities/programmes at national level were fine‑tuned/modified based on monitoring and evaluation activities. The list of countries that participated in the survey is provided in Annex Table 5.A.1.

Source: Country self-assessment responding to the 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community.

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5.3. Community-based IPC measures are vital to safeguard population health

While there are many challenges to measuring the effectiveness of community-based IPC interventions (Box 5.2), understanding the impact of these interventions is integral to ensure that resources are allocated to the measures that offer the greatest health and economic benefits in various community settings.

Box 5.2. Estimating the precise impact of community-based IPC interventions is challenging

Many factors complicate estimating the precise effectiveness of community-based IPC measures (Ford et al., 2014[12]; Gozdzielewska et al., 2022[13]; Jefferson et al., 2023[14]):

• Epidemiology of pathogens: The effectiveness of an individual intervention depends on the epidemiological characteristics of pathogens (e.g. differences in transmissibility, mode of transmission) that the intervention aims to tackle.

• Variation in the design and implementation of IPC programmes: The design and implementation of community-based IPC programmes vary widely across countries and different community settings, making it challenging to pool and interpret the existing evidence.

• Interactions with other interventions: Community-based IPC programmes are often implemented in tandem with other public health initiatives, making it difficult to disentangle the specific impact of each intervention from the collective impact of the programmes implemented simultaneously.

• Diagnostic capacity: Diagnostic capacity reflects the ability to detect infections, including those caused by resistant organisms. The majority of evidence looking at the effectiveness of community-based IPC interventions does not consider the diagnostic capacity across/within each country, nor does it consider the changes in diagnostic capacity over time. The heterogeneity in diagnostic capacity can mean that an IPC intervention that appears effective in certain communities/areas with robust diagnostic capacity may not generate similar benefits in other communities/areas with limited diagnostic capacity, resulting in incorrect conclusions about the effectiveness of the intervention across various settings.

• Measuring compliance with IPC measures: The effectiveness of community-based IPC interventions depends largely on the extent to which community members comply with them in a consistent manner. But accurate measurement of compliance is difficult. Traditional methods (e.g. direct observation) can generate bias whereas self-reported data may not necessarily reflect the actual behaviours.

Source: Ford et al. (2014[12]), “Increasing Hand Washing Compliance with a Simple Visual Cue”. https://doi.org/10.2105/ajph.2013.301477; Gozdzielewska et al. (2022[13]), “The effectiveness of hand hygiene interventions for preventing community transmission or acquisition of novel coronavirus or influenza infections: a systematic review”, https://doi.org/10.1186/s12889-022-13667-y; Jefferson et al. (2023[14]), “Physical interventions to interrupt or reduce the spread of respiratory viruses”, https://doi.org/10.1002/14651858.CD006207.pub6.

Section 5.3 reviews the existing evidence on the effectiveness of the selected interventions against various types of infections and Table 5.1 provides a summary of the findings for each intervention by type of infection. Most evidence suggests that community-based IPC measures are an effective tool to tackle various types of infections such as gastrointestinal and respiratory infections. As expected, the evidence on the precise magnitude of the effectiveness varies substantially, reflecting the differences in study settings and context, as well as the type of infection. The findings on hand hygiene illustrate this point. The existing evidence suggests that promoting hand hygiene in community settings is generally associated with greater reductions in gastrointestinal infections than in respiratory infections, suggesting that hand hygiene on its own is unlikely to control the spread of airborne pathogens. The interpretation of the effectiveness estimates is further complicated by the fact that community-based IPC measures have frequently been used alongside other non-pharmaceutical interventions. This makes the contribution of any single measure difficult to isolate, which is reflected in the substantial heterogeneity of pooled estimates for individual interventions. The results also show that there are very few studies exploring the linkages between community-based IPC measures and resistant infections, highlighting the urgent need for high-quality research.

Table 5.1. Summary findings: Effectiveness of community-based IPC measures by infection type

	Gastrointestinal infections	Respiratory infections	Coronaviruses	Resistant infections
Improving hand hygiene	Vast majority of evidence concludes effectiveness, with pooled estimates in a recent meta‑analysis showing an average 31% reduction in the incidence of infections ([1])	Majority of evidence points to effectiveness, with pooled point estimates from recent meta‑analyses ranging from 16% to 21% reduction in the incidence of infections ([15]; [1])	Reductions were recorded in the incidence of SARS-CoV‑1 and SARS‑CoV‑2 ([13]). The precise magnitude of effectiveness is highly context-dependent.	No studies identified
Enhancing mask wearing	-	Many studies point to effectiveness. The magnitude of protective effects varies by context. Pooled effectiveness estimates generated by two systematic reviews ranging from 11% to 56% depending on the quality of data included in the analysis quality ([16]; [17])	Evidence remains mixed. One Cochrane review of randomised controlled trials concluded little to no effect ([14]). Other systematic reviews including data from real-world experiences calculated a 44% reduction in the incidence of infections caused by SARS‑CoV‑2, MERS-CoV (RR = 0.56; 95% CI = 0.40, 0.79) ([18]) More recently, a 2024 state‑of-the‑science review concluded that masks are effective in reducing the transmission of respiratory diseases when worn correctly and consistently, with a dose‑response effect such that the level of protection increases as adherence to masking increases ([19]). The same review argued that respirators (such as N95, FFP2, or FFP3) are significantly more effective than medical or cloth masks.	No studies identified
Respiratory etiquette	No studies identified	No studies identified	No studies identified	No studies identified
Indoor ventilation	-	No studies identified	Recent analyses point to effectiveness against SARS-CoV‑1, MERS-CoV, SARS‑CoV‑2 ([20])	No studies identified

Note: 1) Gastrointestinal infections are typically caused by consuming contaminated water/food or by having direct contact with an infected individual/surface. Considering this mode of transmission, mask-wearing and indoor ventilation are not expected to reduce the burden of most gastrointestinal infections. In some cases, such as norovirus, which can be airborne for several hours after vomiting, promoting mask-wearing and indoor ventilation would be effective in reducing the burden of infection. 2) Respiratory infections category includes influenza-like illnesses such as infections caused coronaviruses. The table above presents coronaviruses as a separate category to take into account the mounting evidence focussing on illnesses caused by coronaviruses.

Source: OECD review.

5.3.1. Improve hand hygiene

Enhancing hand hygiene is a simple yet effective public health measure to curb the spread of viral and bacterial infections. Many infections are transferred through direct or indirect contact with contaminated objects and surfaces (e.g. handrails, doorknobs). Infectious agents can remain contagious on surfaces depending on various factors such as the specific type of the infectious agent, environmental conditions and surface type, with estimates on the survival time ranging from several hours to more than 12 weeks (Wißmann et al., 2021[21]). Regular hand washing can help interrupt the chain of transmission at the individual level by limiting the transfer of pathogens from contaminated surfaces to hands and from hands to faces or other surfaces. This is particularly important in community settings where individuals often interact closely with one another. Improving hand hygiene is also a valuable tool to fight AMR because it can help reduce the need for using antimicrobials by preventing resistant infections from occurring in the first place.

While most evidence on the effectiveness and cost-effectiveness of hand hygiene comes from health facilities (Box 5.3), improving hand hygiene has also been shown effective in limiting the spread of infections in the community:

• Gastrointestinal infections: One systematic review showed that improving hand hygiene was effective against gastrointestinal infections, with the protective effects averaging at 31% (Relative risk [RR] = 0.69; 95% CI = 0.58, 0.81) compared to no intervention (Aiello et al., 2008[1]).

• Respiratory infections: Improved hand hygiene can also help reduce the risk of respiratory infections though the level of effectiveness has been shown to lower compared to gastrointestinal infections. An earlier systematic review reported that improved hand hygiene was associated with a 16% reduction in the risk of respiratory infections, with the effectiveness estimates ranging from 6% to 44% (Rabie and Curtis, 2006[15]). A subsequent review also concluded that hand hygiene was an effective means to tackling respiratory infections, though it estimated that this intervention was associated with a 21% reduction in the incidence of respiratory infections (RR = 0.79; 95% CI = 0.66, 0.95) (Aiello et al., 2008[1]). More recently, one systematic review evaluated the effectiveness of hand hygiene specifically on infections caused by coronaviruses (Gozdzielewska et al., 2022[13]). This review concluded that improving hand hygiene can help limit the spread of novel coronaviruses such as SARS-CoV‑1 and SARS‑CoV‑2, though this review highlighted that the quality of the existing evidence was low.

Box 5.3. Improving hand hygiene in healthcare settings is highly effective and cost-effective

The latest OECD publication on AMR demonstrates that investing in improving hand hygiene practices in healthcare facilities generates significant health and economic returns

Building on its previous work, the OECD published in 2023 a new analysis – Embracing a One Health Approach to Fight Antimicrobial Resistance – which provided an update on the health and economic impact of antimicrobial resistance (OECD, 2023[22]). A key contribution of the OECD analysis was an evaluation of the effectiveness and cost-effectiveness of 11 interventions and 3 policy packages that, if implemented in desired levels, could limit the deleterious health and economic impacts of AMR in 34 OECD and EU/EEA countries.

The results from the OECD analysis demonstrate that improving hand hygiene is among the most effective and cost-effective healthcare‑based interventions to tackle AMR. In 34 OECD and EU/EEA countries, investing USD PPP 0.48 per capita in hand hygiene can, on average, avoid more than 113 000 resistant and 392 000 susceptible infections every year, prevent more than 4 500 deaths due to resistant infections, help avert more than USD PPP 4 billion in health expenditure and save nearly USD PPP 5.3 billion by contributing to participation in the workforce and leading to gains in productivity.

The health and economic benefits of improving hand hygiene can be amplified if scaled up as part of a multi-sectoral policy package that also includes scaling up antimicrobial stewardship, delaying antimicrobial prescription, increasing mass media campaigns and enhancing food handling practices. Each year, investing in this policy package can, on average, avoid 1.6 million infections, prevent more than 17 000 deaths, save more than USD PPP 9.4 billion in health expenditure and gain around USD PPP 13.8 billion through increased participation in the workforce and improved productivity at work.

Scaling up hand hygiene, either as a single intervention or as part of a policy package, is highly cost-effective. In all 34 OECD and EU/EEA countries included in the OECD analysis, the benefits that can be reaped by improving hand hygiene far exceed the implementation costs. The OECD analysis shows that every USD PPP invested in improving hand hygiene can return nearly USD PPP 25 gained through savings in health expenditure and gains in economic productivity. The return on investment of a policy package that includes hand hygiene is also high, with a return-on-investment equivalent to 5.

Source: OECD (2023[22]), Embracing a One Health Framework to Fight Antimicrobial Resistance, https://doi.org/10.1787/ce44c755-en.

A more detailed look into the existing evidence suggests considerable variation in the effectiveness of hand hygiene programmes depending on the community setting:

• Day care centre‑ and school-based programmes: Improving hand hygiene in schools is a widely deployed community-based IPC intervention that aims to foster good habits to support lifelong healthy behaviours. Generally, children and young people are considered to have an elevated risk of spreading and contracting infections due to their immature immune systems and behavioural factors (e.g. tendency to explore objects with hands and mouth). They have also been suggested to contribute to the transmission of influenza in households (Randle et al., 2013[23]; Viboud, 2004[24]). These factors make day care centres and schools hotspots for disease transmission.

  • Gastrointestinal infections: School-based programmes are effective in reducing the incidence of gastrointestinal infections. One recent Cochrane review that gathered evidence primarily from OECD countries (e.g. Australia, Canada, Denmark, the Netherlands) showed that school-based hand hygiene programmes were associated with an estimated 30% reduction in the incidence of diarrhoea episodes (Incidence Rate Ratio [IRR] = 0.70; 95% CI = 0.58, 0.85) (Ejemot-Nwadiaro et al., 2021[25]), confirming evidence from earlier Cochrane reviews (Ejemot-Nwadiaro et al., 2015[26]; Ejemot-Nwadiaro et al., 2008[27]).

  • Respiratory infections: These programmes can also limit the risk of respiratory infections albeit to a lesser extent compared to gastrointestinal infections. An earlier systematic review examining the effectiveness of hand hygiene interventions in schools and day care centres in Australia, Canada, Finland and the United States found that better hand hygiene was associated with a 16% reduction in the incidence of respiratory illness (RR = 0.84; 95% CI = 0.66, 1.07), with amplified impacts for younger children (RR = 0.80; 95% CI = 0.63, 1.01) (Aiello et al., 2008[1]). Findings from subsequent systematic reviews are aligned with these studies. One recent meta‑analysis focussed on the impact of school-based interventions specifically on the laboratory-confirmed influenza cases. This study demonstrated that school-based hand hygiene interventions, excluding universities, led to reductions in the incidence of laboratory-confirmed influenza cases (Veys et al., 2021[28]). Another recent systematic review made similar conclusions about the relationship between improved hand hygiene and the incidence of influenza among students (Gozdzielewska et al., 2022[13]). However, given its relatively limited effect in childcare and school settings, hand hygiene is unlikely on its own to curb the spread of airborne pathogens.

  • School-based programmes can also reduce school absences. One earlier systematic review analysed the potential effectiveness of hand hygiene promotion programmes using data gathered primarily from studies conducted in OECD countries (Willmott et al., 2015[29]). This review concluded that the vast majority of evidence pointed to an inverse relationship between school-based hand hygiene programmes and absenteeism. Subsequently, one meta‑analysis also found that school-based hand hygiene programmes were associated with a reduction in absenteeism, with the magnitude of the estimated impact ranging from 29.5%- 57.1% (Wang et al., 2017[30]).

• Workplace‑based programmes: Previous studies found high bacterial counts on elevator buttons, keyboards and vending machines and high viral counts on desks, office phones and computer mice and in common areas (e.g. break room sink faucet handles, microwave/refrigerator door handles) (Arbogast et al., 2016[31]), making workplaces a worrisome source of viral and bacterial infections. While teleworking was widespread in OECD countries during the COVID‑19 pandemic (OECD, 2021[32]), a considerable proportion of employees continued to work at offices/shared workplaces (PRC, 2023[33]; EuroStat, 2022[34]) and certain jobs could not be done remotely. These factors make workplace programmes an important platform for community-based IPC measures as part of efforts to promote safer work environments.

• In OECD, workplace‑based programmes are becoming an increasingly popular setting for promoting healthy behaviours (OECD, 2022[35]). Evidence on the effectiveness of workplace‑based programmes to promote hand hygiene remains relatively limited, though generally points to promising results. For example, one recent systematic review that assessed the effectiveness of hand hygiene programmes in workplaces found that the available evidence comes primarily from a handful of studies conducted in OECD countries, including Finland, Germany and the United States (Zivich, Gancz and Aiello, 2018[36]). Findings from these studies suggest that workplace‑based programmes can help improve hand hygiene practices and reduce the incidence of infections. In Finland, employees working in 21 district office units in the Helsinki region were given hand hygiene supplies (e.g. alcohol-based hand rub), coupled with guidance on hand hygiene practices and recommendations on how to limit the spread of infections (e.g. respiratory etiquette). This intervention was associated with around 26% (RR = 0.74; 95% CI = 0.51, 1.05) lower weekly prevalence of gastrointestinal infections compared to no intervention (Hovi, Ollgren and Savolainen-Kopra, 2017[37]). This study found that the risk of respiratory illness also reduced (RR= 0.68; 95% CI = 0.55, 0.82), though this protective effect was only observable when there was no prior exposure to a symptomatic individual.

• Household-based programmes: The evidence on the effectiveness of hand hygiene promotion programmes in households remains limited and the existing evidence is mixed. One of the earlier systematic reviews concluded that improved hand hygiene was associated with notable reductions in the incidence of influenza-like illnesses (Odds ratio = 0.46; 95% CI = 0.22, 0.96) (Warren-Gash, Fragaszy and Hayward, 2012[38]). But findings from subsequent studies have not been consistent with these results. For example, a more recent meta‑analysis also confirmed that promoting hand hygiene in households can be effective against influenza infections (Veys et al., 2021[28]). In contrast, another meta‑analysis found no evidence of protective effects of improved hand hygiene in households against laboratory-confirmed influenza (RR = 1.15; 95% CI = 0.57, 2.32) (Gozdzielewska et al., 2022[13]). Another recent meta‑analysis concluded that improving hand hygiene can lead to very modest reduction in the risk of contracting acute respiratory infections, of the order of 3% (Mo et al., 2022[39]). These mixed results should be interpreted with caution due to the considerable differences in the design of the hand hygiene promotion programmes, outcomes measures used to assess the incidence of illnesses and methodological challenges.

• A deeper look into the existing evidence suggests that hand hygiene promotion at households should start before a household member is infected. The meta‑analysis conducted by Veys and colleagues (2021[28]) noted that hand hygiene promotion falls short of preventing secondary influenza infections if implemented after an initial influenza case (i.e. index case) is identified within the same household. This finding is in line with results generated subsequently by Gozdzielewska and colleagues (2022[13]) who showed in that hand hygiene is also not associated with reductions in the rate of secondary infections of influenza-like illnesses following an index case.

• Other community settings: Evidence on the impact of hand hygiene practices in other settings (e.g. public transport) remains scant but promising. To date, no studies evaluated the effectiveness of hand hygiene promotion in public transportation networks. But previous studies showed that commuters’ hands are frequently contaminated by pathogens (Judah et al., 2009[40]), including antimicrobial resistant bacteria such as meticillin-resistant Staphylococcus aureus (Lutz et al., 2014[41]), suggesting that hand hygiene promotion in public transport networks can be an important strategy to limit the spread of infections.

5.3.2. Encourage wearing face masks

Face masks (e.g. medical and non-medical masks [i.e. fabric] and respirators such as filtering facepiece [FFP] devices such as FFP2/FFP3 or N95] play a key role in community protection during outbreaks by reducing the amount of infectious respiratory particles an individual inhales (protection to the wearer); and by containing infectious respiratory particles an individual produces when infected, even if asymptomatic.

The World Health Organization (WHO) developed a series of guidelines to encourage best practices in mask wearing to curb the spread of SARS‑CoV‑2, the pathogen that caused the COVID‑19 pandemic. These recommendations indicated that in community settings, masks should be worn in specific situations irrespective of the local epidemiological situation including (WHO, 2023[42]):

• following a recent exposure to the pathogen,

• when an individual has or suspects infection,

• when a person is at high risk of severe disease (e.g. persons aged 60 years and over, those with underlying comorbidities such as cardiovascular disease) and

• in crowded, closed or poorly ventilated indoor spaces.

For the general public in most everyday situations, a non-medical mask meeting minimum standards for filtration and breathability is considered adequate (WHO, 2021[43]). Symptomatic individuals are advised to wear a medical mask, in addition to self-isolate and seek medical attention. Respirators are recommended to be reserved primarily for healthcare settings, where they are worn when caring for suspected or confirmed cases and, without exception, during aerosol-generating procedures. In the community, respirators are not recommended for the general public, except for higher-risk individuals in crowded or poorly ventilated environments (WHO, 2023[44]).

The available evidence suggests that face masks can be effective in community settings, although some studies have not observed a measurable impact:

• Synthesis of evidence restricted to randomised controlled trials (RCTs) reported limited effects. One 2023 Cochrane review looked at high-quality evidence from 10 RCTs in community settings and concluded that wearing medical/surgical masks was associated with limited to no reduction in the incidence of influenza-like illnesses (RR = 0.95; 95% CI = 0.84, 1.09) and no observable declines in laboratory-confirmed influenza/SARS‑CoV‑2 (RR = 1.01; 95% CI = 0.72, 1.42) compared to no mask wearing (Jefferson et al., 2023[14]). An earlier meta‑analysis that examined data generated only through RCTs found modest protective effects, with an 11% reduction (RR = 0.89; 95% CI = 0.81, 0.98) in the risk of respiratory infections attributable to mask wearing.

• However, analyses drawing on wider bodies of evidence report protective effects. Using data from RCTs combined with case‑control and cohort studies, Xiao and colleagues (2020[17]) estimated in an earlier meta‑analysis that mask wearing can reduce the infection caused by respiratory viruses by 56% in community settings. Another meta‑analysis that evaluated the effectiveness of mask-wearing against pandemic and epidemic betacoronaviruses (e.g. SARS‑CoV‑2, MERS-CoV) in real-world settings concluded that increased mask wearing in community settings was associated with around 44% reduction in the incidence of infections (RR = 0.56; 95% CI = 0.40, 0.79) (Chu et al., 2020[18]).

• One 2024 state‑of-the‑science review argued that much of this disagreement stems from how the evidence has been analysed rather than from genuine uncertainty about whether masks work (Greenhalgh et al., 2024[19]). Synthesising more than 100 reviews and selected primary studies across multiple disciplines, and re‑analysing contested trials, this review suggested that RCT-only syntheses, including the 2023 Cochrane review ([14]), understate effectiveness by combining dissimilar settings, interventions and heterogeneous outcome measures within single pooled estimates. This review concluded that if worn correctly and consistently, masks reduce the transmission of respiratory infections and exhibit a dose‑response effect with adherence (Greenhalgh et al., 2024[19]). It further argued that respirators are significantly more effective than medical or cloth masks, outperforming surgical masks by roughly eight‑ to 12‑fold in filtering aerosols (Ibid).

Much like other community-based interventions, the effectiveness of mask-wearing interventions depends on the type of community setting. Recent evidence shows that school-based interventions can help curb the spread of infections and help avoid more disruptive measures such as quarantines or school closures. For example, one study conducted in the State of Nebraska in the United States in a school district with 23 000 students and nearly 3 000 staff found that there was no secondary transmission among exposed students when masks were worn in schools (Boutzoukas et al., 2022[45]). This study also found there was a 41% reduction in the frequency of quarantines required for students and school staff with a primary SARS‑CoV‑2 infection in the autumn semester when the masks were used compared to the previous spring semester when no mask-wearing intervention was in place. Promoting mask-wearing in households was also shown effective. In their meta‑analysis, Xiao and colleagues (2020[17]) found that mask wearing was associated with a 40% reduction in the risk of respiratory infections. However, the authors noted that high levels of compliance with mask-wearing was a pre‑requisite for ensuring such high levels of protection.

5.3.3. Enhance respiratory etiquette

Respiratory infections are typically transmitted through respiratory droplets contaminated with viruses and bacteria that are released when an infected individual coughs, sneezes or talks. Respiratory etiquette can interrupt the spread of respiratory infections by minimising the release of contaminated droplets (Wood et al., 2018[46])and by reducing the risk of indirect transmission through contaminated objects or surfaces (WHO, 2021[47]). An important limitation is that respiratory etiquette targets coughing and sneezing and it does not address transmission from presymptomatic,3 asymptomatic4 or sub-clinical infections5 where airborne spread occurs through normal breathing and speaking.

Evidence on the effectiveness of improved respiratory etiquette remains scarce. One earlier systematic review and meta‑analysis that examined the effectiveness of personal protective measures (e.g. mask wearing, hand hygiene) in the context of pandemic influenza identified no studies that attempted to measure the impact of any form of respiratory etiquette (Saunders-Hastings et al., 2017[48]). Similarly, no relevant studies were identified by an extensive literature review conducted by the WHO in 2019 to inform the recommendations on global preparedness against influenza pandemics (WHO, 2019[49]) and by a subsequent systematic review focussing on the effectiveness of non-pharmaceutical interventions in non-healthcare settings (Xiao et al., 2020[17]).

Much like these earlier works, the OECD review did not identify any studies that quantified the potential benefits associated with better respiratory etiquette. Despite the lack of robust scientific evidence, public health authorities strongly recommend bolstering respiratory etiquette considering its potential effectiveness, ease of adoption, acceptability and feasibility (WHO, 2019[49]; ECDC, 2022[50]; CDC, 2016[51]).

5.3.4. Enhance indoor ventilation

The risk of respiratory infections is elevated in poorly ventilated crowded or enclosed spaces (e.g. schools, offices, public transportation networks) due to the greater concentration of contaminated droplets, aerosols and airborne pathogens such as viruses that can suspend in the air for extended periods and spread more efficiently. Better indoor ventilation (i.e. the process by which clean air is introduced intentionally into enclosed spaces while the stale air is removed) and improved air hygiene can reduce the transmission of infections by regulating air quality, temperature and humidity, diluting or removing airborne contaminates and air pollutants (e.g. allergens) and reducing airborne disease transmission (WHO, 2021[52]; Li et al., 2007[53]).

Improving indoor ventilation can involve two methods:

• Natural ventilation: Natural ventilation relies on elemental forces such as wind and thermal buoyancy to facilitate air exchange through openings.

• Mechanical ventilation: Mechanical ventilation actively employs powered components such as fans and air ducts. Air filtration systems (e.g. High-Efficiency Particulate Air [HEPA] filters) can be integrated into mechanical ventilation systems to remove microorganisms and particulates.

The importance of good indoor ventilation has been long acknowledged in healthcare settings (Dai et al., 2021[54]). But the centrality of this measure in community settings only gained more prominence during the COVID‑19 pandemic when it became clearer that crowded and poorly ventilated settings can facilitate the transmission of SARS‑CoV‑2 (Haddrell et al., 2024[55]).

In 2021, the WHO published guidelines and recommendations for improving indoor ventilation in the context of COVID‑19 not only in healthcare settings, but also in non-residential settings (e.g. schools, commercial and religious spaces, workplaces) and residential settings (e.g. homes) (WHO, 2021[56]). In line with findings from recent studies (Thornton et al., 2022[20]), the WHO guidelines indicated that the decision to choose between mechanical/natural ventilation or a hybrid approach depends largely on the specific needs and requirements of the space, resource availability and budgetary considerations (WHO, 2021[56]).

Enhancing ventilation practices, whether by increasing the ventilation rate or by modifying the pattern of airflow, has been shown effective in reducing carbon dioxide and the risk of airborne infections. One recent systematic review that evaluated the relationship between indoor ventilation practices and the spread of coronaviruses (i.e. SARS-CoV‑1, MERS-CoV, and SARS‑CoV‑2) concluded that increased ventilation was associated with reductions in the probability of disease transmission, the concentration of viruses in the air and droplet persistence (Thornton et al., 2022[20]).This study further indicated that increased ventilation was associated with reductions in exposure time to pathogens and increases in virus removal and virus particle removal efficiency.

Much like other IPC measures, the effectiveness of interventions to improve indoor ventilation depends on the community setting:

• School-based interventions: One study conducted in the Marche Region in Italy examined the impact of an intervention that equipped approximately 3% of the region’s classrooms with mechanical ventilation systems between September 2021 and January 2022 (Buonanno et al., 2022[57]). The study found that a one unit increase in per capita ventilation rate was associated with a 12% to 15% reduction in the relative risk of SARS‑CoV‑2 infection. Another intervention carried out in the State of Georgia in the United States also showed that schools that improved indoor ventilation either through mechanical or natural ventilation methods achieved a 35% reduction in the incidence of SARS‑CoV‑2 infections (RR = 0.65; 95% CI = 0.43, 0.98) compared to schools that did not improve the existing indoor ventilation methods (Gettings et al., 2021[58]).

• Workplace‑based interventions: Workplace‑based interventions can be a promising option. One notable example comes from the Fukuoka prefecture in Japan. In this prefecture, the local public health authorities concluded that a COVID‑19 outbreak in August 2021 was linked with insufficient ventilation practices in an office within a manufacturing factory (Kitamura et al., 2022[59]). In response, the existing ventilation systems were redesigned through a hybrid method that combined natural ventilation (e.g. opening doors and windows) and mechanical ventilation (e.g. installing electric and ventilation fans) techniques. The redesign of the ventilation systems led to a rise in the ventilation frequency while the number of employees who were permitted to work in the same office space increased without causing a new outbreak.

The benefits of indoor ventilation extend beyond curbing transmission to a broader set of health and economic co-benefits. Higher ventilation rates have been shown to lower indoor carbon dioxide, and combined with efficient filtration, reduce indoor fine particulate matter (PM2.5), though the magnitude of the potential gain depends also on outdoor air quality (Jones et al., 2021[60]). Reduced exposure to carbon dioxide and pollutants, in turn, is linked to improved cognitive function. For example, an earlier study showed that office workers recorded substantially higher performance under well-ventilated and low- CO₂ conditions (Allen et al., 2016[61]). In school settings, higher ventilation rates in classrooms have been associated with greater academic performance (Haverinen-Shaughnessy, Moschandreas and Shaughnessy, 2010[62]) and reduced illness-related absences (Mendell et al., 2013[63]).

5.4. Improving compliance with community-based IPC measures enhances the effectiveness of these interventions over time

Maintaining a robust culture of good practices in community-based IPC measures is paramount to safeguarding population health over time. Sustaining high levels of compliance can yield important reductions in the overall spread of infections in the community, which can reduce the reliance on healthcare resources (e.g. fewer extra days spent in hospitals), yield greater savings in healthcare expenditure and generate gains in productivity at work. When individuals and communities consistently adhere to the best practices in community-based IPC measures, these best practices can be solidified as societal norms and bolster efforts to better prepare for and respond to future disease outbreaks and pandemics.

The extent to which the community-based IPC measures can effectively safeguard population health depends largely on whether the community members practise them consistently and accurately. High-quality evidence on the level of compliance is scant but the limited evidence suggests low levels:

• One review conducted prior to the COVID‑19 pandemic calculated that globally, only around 19% of the population reportedly wash their hands with water and soap (Freeman et al., 2014[64]). Hand washing prevalence was estimated to be low in OECD countries as well, with the estimates ranging from around 12% in Israel, 50% in the Netherlands and to 52% in the United Kingdom (ibid).

• A nationally representative survey in the United States found that prior to the COVID‑19 pandemic, about 53% of respondents indicated that they remembered to wash their hands after coughing and sneezing (Haston et al., 2020[65]). A subsequent wave of the survey carried out during the COVID‑19 pandemic found that this figure rose to 71% during the pandemic.

• One recent study that evaluated the level of compliance with mask wearing guidelines in 35 European countries in the winters of 2020 and 2021 concluded that the average mask use was around 61% (Spira, 2022[66]). This study reported considerable cross-country variation, with the highest levels of mask wearing being reported in Spain, Italy and Greece (95%, 91% and 84%, respectively) and lowest levels in Denmark and Norway (29% and 14%, respectively). In the United States, one nationally representative survey conducted in August-September 2020 suggested that 60% of the population wore facemasks (Kim et al., 2023[67]).

Considering the interplay between the level of compliance with and the effectiveness of interventions, it is important to examine the factors that influence people’s willingness to comply with community-based IPC measures over time and consider these factors while designing, implementing and fine‑tuning programmes. With this goal in mind, this section explores some of the factors that influence compliance including: 1) situational factors (e.g. during/aftermath of a disease outbreak or pandemic), 2) individuals’ sociodemographic characteristics (e.g. age, sex, occupation), 3) the level of knowledge and understanding about disease transmission and the effectiveness of measures to limit the spread of diseases, 4) the spread of misinformation, 5) risk perceptions and personal beliefs and 6) social norms and beliefs (e.g. stigma).

5.4.1. Compliance ebbs and flows during/after disease outbreaks and pandemics

Compliance with best practices generally improves during disease outbreaks and pandemics. One survey conducted in the United States by the Centers for Disease Control and Prevention in June 2020 showed that compared to October 2019, the odds of remembering to wash hands was around 2.3 times higher among respondents after coughing, sneezing, or blowing their nose and 2 times higher before eating at a restaurant (Haston et al., 2020[65]). In a survey conducted in the United Kingdom, about 83% of respondents reported that they washed their hands more frequently at the time of the survey compared to the pre‑pandemic period (Atchison et al., 2020[68]). Another survey conducted across 14 countries, including 9 OECD countries, found that the trends in hand hygiene mirrored the recent trends in COVID‑19 related deaths and morbidity (Szczuka et al., 2021[69]). This survey showed that compliance with hand hygiene recommendations improved when there was a recent rise (2‑weeks) in the number of COVID‑19 cases and mortality. These findings are aligned with previous studies conducted in the context of other disease outbreaks (Park et al., 2010[70]; Meilicke et al., 2013[71]).

5.4.2. Sociodemographic characteristics influence compliance

At the individual level, certain demographic characteristics are closely linked to compliance. Evidence from several OECD and EU/EEA countries suggests that women tend to have a greater propensity to comply with community-based IPC measures such as hand hygiene, mask wearing and respiratory etiquette compared to men (Haston et al., 2020[65]; Brouard, Vasilopoulos and Becher, 2020[72]). Compliance patterns are also shaped by age, with older age groups generally having greater levels of compliance, including during disease outbreaks (Haston et al., 2020[65]; Nivette et al., 2021[73]; Kim et al., 2023[67]; Brouard, Vasilopoulos and Becher, 2020[72]). Socio-economic status, as measured by educational attainment and/or level of income, is another determinant of compliance patterns. In general, higher levels of education is associated with higher health literacy and greater compliance (Brouard, Vasilopoulos and Becher, 2020[72]; Kim and Yoon, 2022[74]). Economic considerations can also influence compliance patterns (Kim et al., 2023[67]).

5.4.3. Knowledge and awareness can motivate greater compliance

An important determinant of compliance relates to having knowledge and awareness around disease transmission routes. When people have accurate information about how IPC measures can help protect them effectively, they may be more motivated to adopt and sustain these behaviours. The general public’s knowledge of disease transmission and awareness around the effectiveness of community-based IPC measures improved during the COVID‑19 pandemic. For example, one telephone survey conducted in the United Kingdom in 2021 found that there were significant improvements in people’s knowledge of hand hygiene and cough etiquette by March 2021 compared to the same time in 2020 (Read et al., 2022[75]). Yet, efforts to improve knowledge and awareness on their own are unlikely to increase compliance in the long term, especially in the presence of disinformation.

5.4.4. Disinformation has become an important source of non-compliance

Disinformation occurs when false information is shared with the goal of causing harm. Disinformation is different from misinformation, which is the act of sharing false information without the intention to cause harm (OECD, 2020[76]). While accurate knowledge and awareness can enhance compliance, exposure to disinformation can propel non-compliance.

The COVID‑19 pandemic led to an unprecedented surge in the spread of disinformation, including the spread of harmful messaging around the effectiveness of many community-based IPC measures. The wave of disinformation undermined the pandemic response efforts in many OECD countries by crowding out the important information on the effectiveness of mitigation measures, weakening trust in public institutions (Pavela Banai, Banai and Mikloušić, 2021[77]), creating confusion around the effectiveness of measures such as mask wearing and ultimately depressing people’s willingness to comply with the recommended IPC measures in the community (Allington et al., 2020[78]).

The true extent and the impact of misinformation are difficult to measure. Most misinformation is thought to be disseminated online (e.g. social media platforms) and via messaging services that are not open to scrutiny from external observers and content moderators (OECD, 2020[76]). The deleterious effects of exposure to misinformation can be persistent. Recently, one randomised online study from the United States concluded that exposure to misinformation had a negative influence on the attitudes and intentions around mask-wearing (Mourali and Drake, 2022[79]). This study also demonstrated that while debunking false claims can partially improve attitudes and intentions, these positive effects can be washed out when people are exposed to misinformation for prolonged periods.

5.4.5. Risk perceptions and personal beliefs can impact compliance

Risk perception refers to people’s personal beliefs and attitudes towards the risks that they face. Perceptions around the potential severity of disease can influence compliance because in situations where people do not perceive a significant health threat, they may be less inclined to comply with community-based IPC measures. Individuals with inaccurate perceptions around disease severity may adopt behaviours that can be difficult to change over time, undermining efforts to motivate greater compliance with community-based IPC measures in the long term.

Evidence generated during the COVID‑19 pandemic showcases the relationship between risk perception and compliance. One study from Japan conducted during the first wave of the COVID‑19 pandemic in 2020 showed that people who perceived SARS‑CoV‑2 as a significant threat to their own health were more likely to disinfect their hands (Murakami, Yamagata and Miura, 2023[80]). Another study conducted in the United States in March 2020 found a positive association between the likelihood of practicing IPC measures (e.g. hand washing and mask wearing) and the perceived likelihood of personally getting infected, as well as the perceived personal severity of potential infection (Wise et al., 2020[81]).

Personal views and perceptions around the effectiveness of community-based IPC measures can also influence compliance. One recent survey conducted across Austria, Czechia, Poland, Spain and the United Kingdom found that higher disbelief in the protective effects of masks was negatively correlated with mask wearing (Binter et al., 2023[82]). But positive beliefs and perceptions also do not guarantee high levels of compliance. One recent systematic review and meta‑analysis with a global focus showed that globally, around 71% of respondents in the studies included in the review reported that they considered masks as an effective means of infection prevention regardless of the type of disease (e.g. COVID‑19, SARS-CoV, MERS-CoV, H1N1 and H5N1) (Li et al., 2022[83]). Yet only around 68% reported that they would wear masks and only around 54% indicated that they actually wore them.

5.4.6. Societal norms influence health behaviours

Societal norms can also shape compliance. In particular, stigma (i.e. a sense of negative social perception or disapproval towards a behaviour) can impact compliance patterns (Li et al., 2022[83]). Stigma typically arises from a fear of negative social judgement or disapproval towards a certain behaviour (Kim and Yoon, 2022[74]). One recent review of determinants of hand hygiene primarily in OECD countries showed that the risk of attracting social stigma, embarrassment or discrimination was a significant concern against adopting frequent hand hygiene (e.g. worries about creating a perception as “obsessive” or “overly fastidious”) (Teasdale et al., 2014[84]).

The dynamics between stigma and compliance are highly context dependent. Concerns around stigma can depress compliance in certain settings whereas it can produce the opposite effects in other contexts. For example, Japan achieved consistently high levels of compliance with mask wearing recommendations throughout the COVID‑19 pandemic, with approximately 85% to 90% of the population reportedly wearing masks in public spaces (Nippon Research Center, 2023[85]). Mask wearing remained relatively high even after the mask wearing requirements were removed in 2023. Studies focussing on Japan’s experience with pandemic outbreaks suggested that social norms and beliefs dating back to the 1918 influenza pandemic promoted mask wearing (Wada, Oka-Ezoe and Smith, 2012[86]; Burgess and Horii, 2012[87]) and that the desire to conform with these social norms was a key driver of high levels of mask wearing (Li et al., 2023[88]).

5.5. OECD countries can deploy a wide range of policies to promote compliance with community-based IPC measures in the long term

This section presents nine policy options to motivate greater compliance with community-based IPC measures that can be used to address the underlying drivers of compliance in various contexts discussed in Section 5.3 (Figure 5.4). The policies highlighted in the section are not exhaustive and other policies exist including, for example, lifting public science literacy, introduce indoor air quality performance goals, investments in better indoor air quality and improved residential building quality. The policies listed in the figure were prioritised as each applies across all four community-based IPC measures focussed in this chapter.

Figure 5.4. Nine broad policy options OECD, EU/EEA and G20 countries can consider to enhance compliance with community-based IPC measures

Note: IPC = infection prevention and control.

Source: Based on OECD review.

5.5.1. Provide clear guidelines and policy advice to promote best practices

The first step in promoting higher compliance is to provide guidelines and policy advice. Clear guidelines and policy advice can play an important role in promoting higher individual- and community-level compliance by making it easier for people to understand the best practices (Box 5.4). Guidelines and policy advice can also help build a standardised and consistent approach that can be applied in various community settings. They can include performance targets and goals, which can help track compliance over time (Box 5.5) and tailor community-based programmes in accordance with the unique needs of each community.

Box 5.4. In the United States, the “Clean Air in Buildings Challenge” provides recommendations and guidelines to improve indoor ventilation in various community settings

In March 2022, the United States launched a new national call for action called the “Clean Air in Buildings Challenge”, with the aim of improving indoor air quality and indoor ventilation in diverse community settings (EPA, 2022[89]). The guidelines targeted building owners and operators, organisational leaders and decision makers and explicitly underlined the importance of indoor ventilation to tackle infectious diseases that can spread through airborne particles and aerosols.

The initiative laid out four clearly defined strategies with concrete steps that, if implemented systematically, can improve indoor air quality and ventilation practices:

• Creating an action plan for clean indoor air in buildings that assesses indoor air quality, plans for upgrades and improvements and includes HVAC inspections and maintenance

• Optimise fresh air ventilation by bringing in and circulating clean outdoor air indoors

• Enhance air filtration and cleaning by increasing the use of central heating, ventilation, and air conditioning (HVAC) systems and in-room air cleaning devices

• Get the communities engaged in the action plans for clean indoor air in buildings by communicating with building occupants to increase awareness, commitment and participation in improving indoor air quality and health outcomes.

Source: EPA (2022[89]), Clean Air in Buildings Challenge, https://www.epa.gov/system/files/documents/2022-03/508-cleanairbuildings_factsheet_v5_508.pdf (accessed on 7 December 2023).

Box 5.5. Belgium’s new regulatory framework on indoor air quality sets clear definitions and standards for good air quality

In November 2022, Belgium introduced new regulations to improve indoor air quality in all public spaces including workplaces (Service public fédéral Santé publique, 2022[90]). The new regulations clearly highlight the linkages between indoor ventilation and the spread of infectious diseases. They strongly encourage higher ventilation flow rates, which in turn, can help lower the concentration of viruses and other pollutants in indoor spaces.

An important aspect of the new regulations is that they clearly define what constitutes “good quality air” by setting reference levels for CO₂ concentration, minimum ventilation and air purification rates. While they do not oblige those responsible for the spaces to meet the reference levels, they can be used as performance targets to improve ventilation and/or air purification systems. To that end, the new regulations strongly encourage building owners and operators in public spaces to measure indoor air quality (e.g. with a CO₂ metre), assess the potential risks associated with the types of activities that take place in their premises and develop a list of potential causes of indoor pollution.

Source: Service public fédéral Santé publique (2022[90]), Adoption de la loi sur la Qualité de l’air Intérieur, https://www.health.belgium.be/fr/news/adoption-de-la-loi-sur-la-qualite-de-lair-interieur (accessed on 29 June 2023).

The preparation of guidelines and policy advice can be complex, requiring a collection and synthesis of the most recent evidence and identifying the best actions that can fit the needs of communities in setting. In response, many OECD countries and international organisations have been publishing guidelines and recommendations (Box 5.6) to support national and sub-national efforts (Table 5.2).

Table 5.2. Sample recommendations for community-based IPC interventions

Setting	Recommendations
Hand hygiene
Commercial buildings	Provide universal access to hand hygiene stations upon entering and leaving buildings Adapt quantity and usability of the stations to promote optimal use and ensure regular equipment refilling
Public transport facilities	Provide universal access to hand hygiene stations ideally at any public transport facility, especially targeting major bus and train stations, airports and ports Mandate the use of hand hygiene stations before accessing public transport during the COVID‑19 pandemic
All settings	Provide access to free hand hygiene supplies such as alcohol-based hand rub, soap and water Encourage frequent hand hygiene by the population whenever outside of private homes as a routine activity
Mask wearing
In 4 key moments	In crowded, enclosed or poorly ventilated spaces Following a recent exposure to COVID‑19 when sharing a space with others While sharing a space with a person displaying COVID‑19 symptoms is COVID‑19 positive and For individuals who are at high-risk of severe complications from COVID‑19
Respiratory etiquette
All settings	Cover mouth and nose when coughing or sneezing Use tissues and throw them away Wash hands or use a hand sanitiser every time after touching mouth or nose
Indoor ventilation
Improving air circulation within buildings	Ensure existing HVAC systems are providing at least the minimum outdoor air ventilation requirement in accordance with ventilation design codes Increase the introduction of outdoor air beyond code‑minimum requirements Use fans to increase the effectiveness of open windows. Rebalance or adjust HVAC systems to increase total airflow to occupied spaces when possible. Introduce indoor air quality performance goals Monitor and display air quality Encourage HVAC system maintenance Develop ventilation guidelines

Note: HVAC = heating, ventilation and air conditioning.

Source: Sample recommendations were extracted from (WHO, 2020[91]) for hand hygiene, from (WHO, 2023[42]) for mask wearing and adopted from (CDC, 2023[92]) for indoor ventilation.

Box 5.6. France puts forward a novel hygiene measure framework for preventing infectious diseases in the community

In 2023, France’s High Council for Public Health (HCSP) issued new guidelines on the use of hygiene measures in community settings. The recommendations span ten core measures from hand hygiene to improved indoor ventilation and are intended for year-round application, with particular emphasis during outbreak seasons (Conseil de la santé publique, 2023[93]). They align closely with the principles of the Ottawa Charter for Health Promotion, notably its calls to develop sound public policy, create supportive environments, strengthen community engagement, build individual skills and reorient health services.

The HCSP also provides a set of broader recommendations aimed at reducing the overall burden of major infectious diseases. These include, but are not limited to, ensuring access to essential hygiene products for vulnerable populations (e.g. soap, water, personal hygiene supplies, household products and municipal shower facilities); establishing a monitoring committee to oversee universal hygiene measures and related communication; developing educational toolkits or hygiene kits alongside targeted communication campaigns; and systematically evaluating measures, for example, through health impact assessments where appropriate that extend beyond the health sector.

Source: Conseil de la santé publique, (2023[93]), Mesures universelles d’hygiène pour la prévention des principales maladies infectieuses dans la population générale Collection Avis et Rapports, https://www.hcsp.fr/explore.cgi/avisrapportsdomaine?clefr=1289 (accessed on 18 August 2024).

National pandemic preparedness plans typically include recommendations and policy advice for the implementation of community-based IPC measures. A deeper look into these documents points to their strengths and weaknesses (Figure 5.5). One positive finding is that all national pandemic preparedness plans in G7 countries set clear goals and objectives and clearly identify high-risk populations that should be considered during a disease outbreak. Frequently mentioned high-risk groups include children, pregnant women, older people and immunocompromised people. All these documents highlight the potential need for school- and workplace‑based programmes in case of disease outbreaks. Covering the needs of households is also mentioned but less frequently.

Despite their strengths, national pandemic preparedness plans in G7 countries do not consistently discuss considerations around the centrality of compliance in the community with the vision that they lay out. Only 4 out of 7 national action plans mention the importance of ensuring high levels of compliance in the community. Even when compliance is discussed, this is usually done in a cursory manner and without putting forward any strategies to motivate greater adherence in the community. Finally, even though the importance of monitoring and evaluating the implementation of the activities highlighted in the national plans was discussed in all documents, none of these documents indicate having indicators to track community-level compliance over time.

Figure 5.5. In G7 countries, pandemic preparedness plans do not consistently address concerns around compliance

Note: Figure above shows whether the pandemic plan i) sets clear goals and objectives, ii) it references high-risk populations, including children, pregnant women, older people and immunocompromised people, iii) highlights the need for school-, workplace‑ and/or household-based programmes in the case of outbreaks, iv) mentions the importance of ensuring high levels of compliance in the community, v) refers to the importance of monitoring and evaluating the implementation of the activities highlighted in the national plans and vi) includes indicators that can enable tracking of compliance in the community over time. M&E = monitoring and evaluation of the implementation. The list of pandemic preparedness plans and other relevant documents reviewed by the OECD are provided in Annex Table 5.C.1.

Source: OECD review.

5.5.2. Ensure adequate access to supplies and materials

Compliance can also be influenced by the availability of IPC supplies and materials (e.g. soap dispensers and facemasks), especially during disease outbreaks. In the early days of the COVID‑19 pandemic, shortages in facemasks and hand sanitisers were pervasive globally and in many OECD countries. In response, 18 out of 24 OECD Members and accession countries that participated in the OECD survey distributed free‑of-charge masks and 16 countries distributed handwashing materials through national and sub-national programmes. Some OECD countries have also taken initiatives to distribute air purifiers as part of a broader effort to ensure a safe return to schools (Box 5.7).

Evidence suggests that in OECD, IPC supplies and materials were in short supply in certain community settings even before the COVID‑19 pandemic. For example, one study from the Netherlands showed that 43% of playrooms lacked either a sink, soap dispenser in reach of children or a towel facility (van Beeck et al., 2015[94]). Another study from New Zealand found that around 15% of public toilets lacked soap (Wilson and Thomson, 2021[95]). Findings from these studies broadly align with those showing that interventions that combine activities to increase the accessibility of IPC supplies and materials with efforts to increase awareness and understanding tend to produce greater compliance compared to activities that solely focus on educational or behavioural interventions.

Box 5.7. A school-based programme in Australia used air purifiers and high efficiency particulate air filters to facilitate safe return to in-person teaching during the COVID‑19 pandemic

One school-based programme implemented in the State of Victoria in Australia between 2021 and 2022 aimed to facilitate safe return to in-person teaching by improving indoor ventilation practices (Government of the State of Victoria, 2023[8]). As part of the programme, the Department of Education provided eligible schools with around 111 000 air purifiers and enough HEPA filters to cover every classroom for two years. These types of filters are generally considered to be highly efficient in removing airborne contaminants, making them increasingly crucial for ensuring high indoor air quality. Extra air purifiers were held in storage to account for potential increases in enrolment and/or the addition of new classrooms. In addition, natural ventilation practices (e.g. doors and windows, engaging in outdoor learning during warmer seasons) were encouraged. The State of Victoria was estimated to allocate over USD 190 million to the programme for two years of implementation. The Department of Education assessed the implementation of the programme in a sample of schools. This evaluation concluded that a key challenge involved finding a balance between ventilation strategies and ensuring a comfortable learning environment, as well as potential trade‑offs around energy and thermal efficiency.

Source: Government of the State of Victoria (2023[8]), School operations – Ventilation and Air Purification, https://www2.education.vic.gov.au/pal/ventilation-air-purification/policy.

5.5.3. Financial incentives

Financial incentives have long been used to promote good public health practices such as encouraging the prudent use of antibiotics (Yoshikawa et al., 2021[96]). Financial incentives can be in the form of rewards and penalties. Both types of financial incentives have been shown effective. The potential impact of financial incentives on compliance rates is likely to depend on a range of factors such as the community context, public attitudes, social and cultural norms, and the magnitude of the penalty/reward.

Positive financial incentives (e.g. rewards, subsidy programmes) can be considered especially when cost considerations create a barrier against adoption. For example, mechanical ventilation imposes a range of upfront and operating costs, which can influence the selection of ventilation strategy (Table 5.3). One recent multi-country survey conducted in 7 OECD countries (i.e. Austria, Belgium, Denmark, Estonia, France, Norway and the United Kingdom) showed that high capital costs were highlighted as one of the main barriers hindering the widespread adoption of mechanical ventilation systems (Zukowska et al., 2020[97]). In this case, using positive financial incentives (e.g. rewards, subsidy programmes) can be one option to encourage building operators and owners. Despite their promise, financial incentives remain an underutilised tool, as only Austria, Germany, Israel, Japan and the United Kingdom reported in the OECD survey that they used some type of financial incentive to promote better indoor ventilation practices during the COVID‑19 pandemic.

Table 5.3. Sample cost estimates for various ventilation interventions

Ventilation strategy	Up-front cost	Ongoing maintenance requirements and incremental energy usage
Using fans to increase effectiveness of open windows	<USD 100	No ongoing maintenance requirements Incremental energy use varies, depending on HVAC system capacity and ambient outdoor conditions
Adding in-room HEPA fan/filter systems	Approximately USD 500	Must inspect/replace HEPA filter per manufacturer instructions Low incremental energy use
Adding upper room ultraviolet germicidal irradiation (UVGI) [Typical classroom requires 2‑3 fixtures]	< USD 1 500 (approx. per fixture)	Must clean/inspect/replace UVGI lamps per manufacturer instructions Low incremental energy usage

Note: HEPA = high efficiency particulate air; HVAC = Heating, ventilation and air conditioning; UVGI = Ultraviolet Germicidal Irradiation.

Source: Adapted from CDC (2023[92]).

In contrast, negative incentives (i.e. penalties, disincentives) impose a cost for failing to engage in the desired behaviours. Negative incentives can be considered when compliance with certain IPC practices is crucial to ensure public health and to discourage non-compliance. For example, the OECD survey found that 17 out of 24 OECD Members and accession countries imposed financial penalties for non-compliance with mask wearing regulations during the COVID‑19 pandemic. Countries that consider implementing negative incentives should carefully think through the severity of the penalties that they plan to impose. Penalties with mild consequences (e.g. warnings or small fines) might act as a reminder and encourage greater compliance without inciting strong negative reactions whereas stronger penalties may be perceived as punitive.

5.5.4. Design and implement effective community-based IPC programmes

Community-based interventions tend to be more effective when they involve multiple components. For example, one earlier systematic review found that hand hygiene education alone was only moderately effective (RR=0.86; 95% CI = 0.73, 1.00) against respiratory illness (Aiello et al., 2008[1]), whereas an intervention that combined hand hygiene education with the distribution of nonantibacterial soap was associated with greater reductions in respiratory illness rates (RR=0.49; 95% CI = 0.40, 0.61). More recently, Ejemot-Nwadiaro and colleagues (2021[25]) also showed that in school settings, interventions that combined both the distribution of hand-washing supplies and promotional materials were more effective in reducing the incidence of diarrhoea episodes compared to interventions that relied solely on awareness raising (IRR = 0.66; 95% CI = 0.58‑0.75 vs. IRR = 0.84, 95% CI = 0.67‑1.05).

Decisions around the duration of the implementation also matter. Changing habits and behaviours around hand hygiene, mask-wearing and respiratory etiquette takes time and solidifying habits and behaviours requires long-term efforts. Educational messages, behavioural nudges and financial incentives may be repeated over an extended period for people to internalise new habits and behaviours. Previous studies show that the effectiveness of hand hygiene interventions improve over time (Aiello et al., 2008[1]), aligning with results from other health promotion activities (Cradock et al., 2014[98]).

Interactions between different public health objectives should be carefully weighed in the design of IPC measures in the community. For example, as highlighted in the 2021 WHO roadmap, certain interventions such as mosquito screening may inadvertently hamper the rate of natural ventilation (WHO, 2021[52]). Keeping in mind that many OECD countries are experiencing a surge in vector-borne diseases, adopting comprehensive approaches that take into account various public health objectives (e.g. strengthening vector control) while improving indoor ventilation remains a key consideration (Semenza and Paz, 2021[99]).

Another key consideration is the unintended consequences arising from the implementation of these programmes. For instance, improving indoor ventilation can increase energy consumption and utility bills and lead to a higher carbon footprint. This was the case when the city of Pamplona in Spain introduced new guidelines that promoted greater use of natural ventilation (e.g. opening all doors and windows at the end of each class and during short breaks) in order to halt the spread of SARS‑CoV‑2 between March 2020 and January 2021. One study that examined the impact of this initiative found that while the new guidelines led to a 55% reduction in CO₂ concentration in indoor spaces in schools, they also resulted in a marked rise in heat consumption during winter (Monge-Barrio et al., 2022[100]). Recent evidence suggests that mechanical ventilation systems with heat recovery units could reduce the additional heating demand. For example, one study in Italy in a school setting found that mechanical ventilation systems equipped with heat recovery units cut the ventilation share of energy loss to 5% and delivered overall energy savings above 30% (Stabile et al., 2019[101]).

5.5.5. Improve public awareness and understanding

Educational initiatives and mass education campaigns can play a vital role in improving compliance by enhancing people’s awareness and knowledge of infection prevention and control in the community, dispel misinformation while promoting accurate guidelines and best practices. These initiatives can reach a wide audience quickly and effectively. Repeated exposure to the messages highlighted by these initiatives can help reinforce and maintain high levels of adherence with the best community-based IPC practices in the long term.

Throughout the COVID‑19 pandemic, the OECD Members and accession countries made substantial efforts to inform the public about the spread of SARS‑CoV‑2 and strategies to slow its transmission in the community (Figure 5.6). Specifically, 22 out of 24 OECD Members and accession countries reported that they launched public awareness campaigns to promote hand hygiene and mask wearing and 20 countries had campaigns to promote respiratory etiquette during the COVID‑19 pandemic. However, only a fraction of these campaigns had monitoring and evaluation arrangements that could be a basis for fine‑tuning/modifying the implementation arrangements. Some countries continued their educational initiatives in the aftermath of the pandemic. For example, Slovenia reports that the National Institute of Public Health has been implementing awareness raising activities to encourage best practices in respiratory etiquette and indoor ventilation in the general public.

In addition to mass media campaigns, the OECD Members and accession countries used free‑of-charge phone lines/websites to facilitate access to accurate information about the effectiveness of community-based IPC measures. Of the 24 OECD Members and accession countries reported in the OECD survey that they had free‑of-charge phone lines/websites to provide accurate information on hand hygiene, mask wearing and respiratory etiquette. However, much like larger scale awareness campaigns, only a fraction of these phone lines/websites were finetuned/modified based on feedback received through monitoring and evaluation mechanisms.

Figure 5.6. OECD Members and accession countries frequently relied on mass media campaigns during the COVID‑19 pandemic

Number of countries that reported organising mass media campaigns during the COVID‑19 pandemic to promote greater compliance with community-based IPC measures

Note: This graph presents the number of countries that responded to the questions “How did your country encourage better hand hygiene/mask-wearing/respiratory etiquette in the community during the COVID-19 pandemic?” by selecting the option “Organise mass media campaigns to encourage best practices in hand hygiene/mask-wearing/respiratory etiquette”. Levels of implementation include: No plans = No plans for implementation; Regional/sub-national = Activities/programmes were implemented at the regional/sub-national level; National = Activities/programmes were implemented at the national level; National, M&E = Implementation of activities/programmes at national level were fine‑tuned/modified based on monitoring and evaluation activities. The list of countries that participated in the survey is provided in Annex Table 5.A.1.

Source: Country self-assessment responding to the 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community.

Robust evidence on the effectiveness of mass media campaigns on motivating greater compliance with community-based IPC measures remains limited but available data suggests promising results. For example, one social media campaign launched in 2020 in the Netherlands disseminated best practices in hand hygiene through a news article with infographics published in a newspaper with 2 million readers and a video campaign designed by an influencer with a following of around 80 000 people (Yousuf et al., 2020[102]). This campaign resulted in notable improvements in hand hygiene behaviours. Exposure the infographics alone was positively associated with improved hand-washing practices (Odds ratio [OR] adjusted for age, gender and educational attainment = 1.31; 95% CI = 1.22‑1.40). Importantly, exposure to both the infographics and the video campaign compounded the positive impact of this intervention on hand hygiene behaviours (adjusted OR = 2.14; 95% CI = 1.83‑2.50). These findings are broadly aligned with other studies conducted in non-OECD countries (Hanson et al., 2020[103]; Scott et al., 2008[104]).

Existing evidence focussing on the effectiveness of initiatives that aim to improve awareness and understanding around various public health challenges underline that these activities should carefully consider several factors including:

• Identifying the target audience: Creating an effective mass media campaign requires to clearly identify the target audience of the activities aiming to improve awareness and understanding (Tidwell et al., 2019[105]). Once the target audience is defined, the specific design features of informational activities can be carefully tailored to achieve the highest levels of effectiveness (Box 5.8).

• Using clear and compelling public health messaging: Previous studies focussing on the effectiveness of interventions to improve the public’s understanding and awareness of public health challenges such as antimicrobial resistance underline the importance of using clear and compelling public health messages that are tailored to specific population groups (e.g. school-children and parents) (Price et al., 2018[106]; Parveen et al., 2022[107]).

• Evaluating the effectiveness of educational initiatives: Evidence emerging from studies focussing on educational initiatives suggests that defining specific and measurable goals early on (e.g. increasing the frequency of hand washing, improving knowledge around respiratory hygiene) is crucial to help assess the effectiveness of these interventions (Yousuf et al., 2020[102]). Regular evaluations of educational initiatives can help identify the areas that need to be fine‑tuned in the implementation of these activities.

Box 5.8. School-based interventions can consider using vocal, visual and interactive elements to enhance their effectiveness

Vocal and visual elements can grab the attention of young children

One pilot study in the United Kingdom tested the effectiveness of persuasive space graphics (e.g. graphic elements integrated within an architectural environment) in 3 schools and one museum (Dingman, Wu and Murphy, 2020[108]). This study found that graphic reminders increased the frequency of handwashing by about 50% after two to three months, coupled with enhancements in the average quality of the handwashing. In the United States, one programme targeting pre‑school children 3‑5 years of age used a blacklight technology to visually demonstrate the residual contamination after washing hands (Dingman, Wu and Murphy, 2020[108]). This study reported improvements in hand hygiene behaviours over five months.

Interactive elements can also augment compliance

Using interactive elements can also augment compliance. One RCT conducted in Türkiye evaluated the effectiveness of a hand hygiene intervention in two kindergartens (Arıkan et al., 2018[109]). The intervention group participated in four sessions where a clown provided information about microbes, demonstrated proper handwashing techniques, and engaged the children in interactive activities and videos. The results showed a 34.6% difference in microbial contamination between the intervention and control groups. Another randomised controlled trial from the United Kingdom evaluated the impact of an educational programme called “A Germ’s Journey”, which targeted younger children between 4 and 5 years of age (Younie et al., 2020[110]). The intervention involved presenting children with books, online games and a gel to make them observe residual contamination after handwashing. This intervention was associated with a 40% increase in children’s knowledge of how germs are transferred and an 18% improvement in observed handwashing behaviours such as washing under fingernails.

Source: Dingman, Wu and Murphy (2020[108]),“School-based, blacklight handwashing program can improve handwashing quality and knowledge among pre-school aged children”, https://doi.org/10.1016/j.evalprogplan.2019.101731; Arıkan et al. (2018[109]), “The Effect of Therapeutic Clowning on Handwashing Technique and Microbial Colonization in Preschool Children”, https://doi.org/10.1111/jnu.12392; Younie et al. (2020[110]), “Improving young children’s handwashing behaviour and understanding of germs: The impact of A Germ’s Journey educational resources in schools and public spaces“, https://doi.org/10.1371/journal.pone.0242134.

5.5.6. Behavioural nudges

Establishing and maintaining good IPC habits can be challenging even in settings where the knowledge of IPC measures is already high. Behavioural nudges can be considered as an alternative strategy to motivate greater compliance. Unlike other approaches such as financial incentives, behavioural nudges (e.g. visual cues, reminders, defaults, improving convenience and gamification) aim to guide individuals’ behaviours without directly regulating their choices.

Instead, behavioural nudges attempt to influence behaviours by making the desired behaviours more visible, attractive or convenient for its target audience. During the COVID‑19 pandemic, 14 out of 24 OECD Members and accession countries reported in the OECD survey that they encouraged the use of contactless credit card payments in businesses in order to improve the convenience of financial transactions for customers. This intervention was thought to reduce the incidence of SARS‑CoV‑2 by minimising the physical contact between the payment terminals, reducing the need for using cash – cash can be a source of infections become it can chance hands frequently – and finalising transactions faster.

The choice of the specific behavioural nudge should consider the target audience. For example, in day care/school-based programmes, it might be more beneficial to use gamification strategies (Box 5.9), whereas workplace programmes may consider using rewards and team-based activities targeting employees (Box 5.10).

Box 5.9. e‑Bug Project in the United Kingdom uses gamification strategies to promote healthy IPC behaviours among children and young people

The e‑Bug Programme, operated by the United Kingdom Health Security Agency, is a health education programme that aims to promote healthy IPC behaviours (e.g. respiratory etiquette) among children and young people (e-Bug Project, 2022[111]). It provides free educational materials and resources for educators, parents, caregivers and community leaders. The e‑Bug Programme approach provides important lessons for using gamification strategies designed specifically for a young audience.

The e‑Bug educational materials also make use of various gamification strategies to promote greater engagement depending on the playing needs and cognitive abilities of children in various age groups (e-Bug Project, 2022[111]). For example, the e‑Bug Junior Game, targeting children between 9‑12 years of age, is designed similarly to fast-engaging platform games (e.g. Mario series), fast-reaction games (e.g. Whack-a-mole) and quiz games. Typically, in these games, the player is around the same size as a bacterium, navigates the environments in which that they exist, and they earn points/rewards through interactions with microbes (e.g. the player throws a soap at harmful microbes to wash them off.) In comparison, the e‑Bug Senior Game, targeting older students between 12‑14 years of age makes use of the Problem-Based Learning methodology. The players are typically given a detective style investigative scenario related to a disease outbreak in Europe whereby they are expected to find the source of infection/contamination in order to successfully complete the game.

Source: e‑Bug Project (2022[111]),KS1/KS2/KS3 Respiratory Hygiene Experiment – Snot Gun Runway, https://www.youtube.com/watch?v=0fXQWJzxtII (accessed on 15 November 2023).

Box 5.10. Employee wellness programmes can consider team-based activities and rewards to promote better compliance

One employee‑wellness programme conducted in a private company in the State of Georgia in the United States for 3‑months between 2012 and 2013 provides useful lessons for designing workplace‑based IPC programmes that can promote greater compliance among employees (Thompson and Rew, 2015[112]). This programme aimed to improve hand hygiene behaviours among more than 1 600 employees working in an office building through a multi-modal programme that combined messaging with behavioural nudges. Educational messages included information on bacterial pathways, germ fears, anxiety and myths and IPC practices that employees can use to interrupt the transmission of diseases. Educational messages were disseminated through posters and fliers and weekly emails.

Behavioural nudges such as team-based activities and rewards can help motivate compliance

Employees were voluntarily assigned to small and co‑operative teams. Each employee monitored their level of healthy habits each day (e.g. washing hands with hot water and soap, use of hand sanitisers etc.). The programme organisers assigned points to employees for participating in key activities. The programme organisers carried out regular bacterial audits to assess the contamination levels in dedicated employee spaces and common areas. Teams were awarded points for successfully reducing the contamination levels in their associated spaces. Team scores and ranking were announced on a weekly basis to create an environment of competition. At the start of the programme, hand hygiene products were labelled “Wash, Wipe and Sanitize” and were made easily accessible (e.g. in desks, common areas and near critical touch points such as elevators) in order to make it more convenient for employees to practise hand hygiene.

Team-based activities and rewards can help motivate compliance

An evaluation of the employee wellness programme showed a 37% reduction in the contamination levels across all the surfaces and equipment measured in the office space compared to the baseline. The programme was also associated with notable reductions in healthcare spending, with the average monthly cost of medical services associated with minor illnesses across employees reducing from USD 45.96 in six months before the start of the programme to USD 32.88 in 6 months after the programme ended. The programme was also shown to yield gains in productivity at work, with a 13% reduction in the number of days absent from work due to ill health.

Source: Thompson and Rew (2015[112]), “The Healthy Workplace Project: Results of a Hygiene-Based Approach to Employee Wellness”, https://doi.org/10.4278/ajhp.130830-ARB-459.

The OECD survey showed that the OECD Members and accession countries relied frequently on two types of behavioural nudges in the context of the COVID‑19 pandemic to promote greater compliance: 1) visual cues and 2) Short messaging services (SMS)-based reminders.

Visual cues

Even before the COVID‑19 pandemic, visual cues were increasingly used to nudge healthy behaviours. During the COVID‑19 pandemic, OECD Members and accession countries frequently relied on visual reminders to promote best practices (Box 5.11). For example, 23 out of 24 OECD Members and accession countries reported in the OECD survey indicated that they placed visual cues in highly visible areas to promote hand hygiene, mask wearing and respiratory etiquette during COVID‑19.

Box 5.11. Behavioural nudges are an integral part of Ireland’s approach to enhancing hand hygiene in public spaces

In 2020, Ireland put together a list of key approaches and 10 concrete steps that can be used to improve hand hygiene in public places (Irish Department of Health, 2025[113]). The recommended approaches and actions aimed to address various drivers of compliance, ranging from the accessibility of hand hygiene materials to raising the awareness of individuals on the benefits of better hand hygiene.

A key important feature of Ireland’s approach entails using behavioural nudges (e.g. visual cues in key spaces, modelling good behaviours by managers and supervisors) that promote developing and sustaining good hand hygiene behaviours and combining these nudges with other measures that ensure adequate access to hand hygiene materials.

Table 5.4. Example approaches that can be used to improve hand hygiene in public places

Key approaches	Actions
Ensure awareness of the benefits of and techniques for good hand hygiene	Make people aware of the benefits of good hand hygiene Make people aware that they/their family are probably not using the correct techniques Show the required HH steps
Provide visual cues in restrooms to remind people to wash and dry hands	Provide visual reminders in restrooms (e.g. posters above the sink, on the back of stall doors and above urinals) Install automatic towel dispensers that dispenses a towel upon approach to the sink Add directional arrows from stalls to sinks Use audio-visual reminders
Ensure that hand sanitisers are available, visible and easy to use	Make hand sanitisers available when handwashing is not feasible Place the location of hand sanitiser dispensers at convenient points to maximise use In the direct routes that people walk (e.g. at the centre of an entrance lobby) Within easy reach (e.g. on carts as well as walls, at the entrance to rooms) Before/after tasks are completed (e.g. entry to / exit from a shop or room) Where people normally take a pause (e.g. at an elevator) Ensure that signage for hand sanitiser dispensers are available Do not limit access to the dispenser Do not diminish the visibility of visible dispensers In informational materials, keep text to minimum
Model good behaviours, help staff to form HH habits and provide regular feedback	Managers, supervisors and influencers can model good behaviours Provide regular performance feedback on compliance Help staff link hand hygiene with common events (e.g. getting to work, start of meetings)

Source: Adapted from Irish Department of Health (2025[113]), Using Behavioural Science to Improve Hand Hygiene in Workplaces and Public Places, https://assets.gov.ie/73613/c5b00da7b6c14afca8de2bf729697d9c.pdf (accessed on 3 May 2023).

A growing body of evidence suggests that visual cues are an effective means to motivate greater compliance with community-based IPC measures. Earlier studies conducted in healthcare settings demonstrated that incorporating visual cues into the physical environments led to improvements in hand washing rates among health workers over time (McGuckin and Govednik, 2013[114]). Results from subsequent studies conducted in community settings concur with these findings. For example, one study conducted in the State of North Carolina in the United States involved installing visual cues (e.g. motion activated dispensers that automatically presented towels and soap dispensers) in public bathrooms (Ford et al., 2014[12]). This study showed a nearly 23% increase in towel use and around 13% increase in soap use. A subsequent study conducted in the State of Carolina used large, red arrow shaped stickers as visual cues (Blackwell, Goya-Tocchetto and Sturman, 2017[115]). The stickers were purposefully placed as lines directing people from urinals/stalls to hand washing stations in order to create a natural flow. This study found a 15% overall increase in hand washing practices.

Visual cues have also been shown to encourage better indoor ventilation practices, though the evidence points to uneven effects. One study in Denmark alternated two‑week periods in which teachers and students were instructed to open windows in response to visual CO₂ feedback against periods of normal ventilation. This study found that the use of the visual cue was associated with more frequent window opening (Wargocki and Da Silva, 2014[116]). A more recent study installed a display alerting teachers when CO₂ exceeded set thresholds and recorded a 19.5% reduction in concentrations (Rawat et al., 2025[117]). This study also reported, however, a rise in classroom PM particulates as windows were opened more often and energy use increased due to heat loss. In comparison, one study in Denmark compared alternative retrofits across adjacent classrooms and found that visual feedback alone did not motivate window opening: display-equipped classrooms matched manually operated ones at up to 17% of occupied time, against 49% to 71% under automatic control (Heebøll, Wargocki and Toftum, 2018[118]).

Text- and/or voice‑based reminders

Many countries turned to text- and/or voice‑based reminder services as part of their COVID‑19 information campaigns though there were substantial differences in the design and implementation. For example, some countries such as Germany relied on national-level initiatives to promote better hand hygiene, respiratory etiquette and mask wearing whereas other countries such as Australia adopted a more decentralised approach by implementing regional/sub-national programmes.

In 2020, the WHO launched a new message library to address the increasing demand for SMS-based public health messaging (WHO, 2020[119]). This message library collated a list of suggested messages designed to inform the general public on a variety of topics including, infectious diseases and disease transmission and community-based IPC measures such as hand hygiene, mask wearing and respiratory etiquette (Table 5.5). The suggested messages were short and easy to understand and countries that considered using them were encouraged to adapt them to the local contexts and languages.

Table 5.5. Sample messages included in the WHO COVID‑19 message library to promote compliance with community-based IPC measures

Theme	Sample message
Handwashing	Wash your hands after coughing or sneezing, when caring for the sick, when preparing food, before eating, after toilet use, after handling animals
Mask-wearing	Before putting on a mask, clean hands with alcohol-based rub or soap and water. Avoid touching the mask while using it and remove it from behind
Respiratory etiquette	Stop the spread: Cover your mouth and nose with a bent elbow or tissue when you cough or sneeze. Dispose of used tissues immediately and wash hands regularly.

Source: WHO (2020[119]).

Even before the COVID‑19 pandemic, SMS-based messaging initiatives have been shown to propagate a rise in healthy behaviours, such as smoking cessation (Scott-Sheldon et al., 2016[120]), greater adherence to prescribed medications and higher treatment completion rates (Alipanah et al., 2018[121]; Orr and King, 2015[122]). Evidence generated during the COVID‑19 pandemic suggests that SMS-based interventions can be effective, but their impact is generally modest. One recent study from Korea found that the emergency text messages in 2020 sent by the national and local governments during the COVID‑19 pandemic were positively associated with preventive behaviours. Specifically, receiving and reading emergency text messages was associated with approximately 12.6% rise in mask wearing and almost 8% increase in hand washing (Lee and You, 2021[123]). A randomised controlled trial conducted in the city of Sao Paulo in Brazil in 2020 also suggested that receiving a text message was associated with significant increases in the probability of wearing a mask when leaving home in the last seven days and a greater likelihood of adhering to social distancing guidelines (Boruchowicz et al., 2020[124]). Importantly, these studies emphasised that the effectiveness of SMS-based messaging is highly sensitive to the frequency and framing of the messages.

5.5.7. Set up routine monitoring and evaluation systems

Monitoring and evaluating the implementation of community-based IPC interventions can be an effective strategy to fine‑tune the design of these interventions and helps improve the level of compliance in the general public. Routine monitoring and evaluation can provide an opportunity to identify the bottlenecks in the implementation and the factors that may hinder the public’s level of compliance with the IPC measures.

Monitoring and evaluation remains an overlooked area in national and international guidelines. One recent study concluded that only 4% of international guidelines on hand hygiene recommend supporting or bolstering the existing monitoring systems or developing new monitoring systems aligned with global hygiene indicators (MacLeod et al., 2023[125]). Consistent with this finding, the OECD survey also found that only 7 out of 24 OECD Members and accession countries incorporated monitoring and evaluation plans in their national pandemic preparedness plans, legislation, policies and/or programmes to track the mask wearing practices in the community. Similarly, only 5 countries include monitoring and evaluation plans focussing on hand hygiene and respiratory etiquette and only 2 countries have similar plans for monitoring indoor ventilation practices.

Establishing routine monitoring and evaluation systems for community-based IPC interventions can be difficult because these programmes can be resource intensive, requiring funding and technical expertise. Compliance may vary considerably even among members of the same community, requiring a deep understanding of the community and the unique contextual factors that drive the level of adherence. As discussed in Section 5.3, these contextual factors can be dynamic, for example, due to the trajectory of disease outbreaks. Collection of reliable data can also be challenging because these programmes often rely on self-reported measures, which can be biased.

Despite these challenges, building monitoring and evaluation mechanisms for community-based IPC measures is feasible as part of efforts to prepare for future outbreaks. Table 5.6 presents sample strategies that OECD countries can consider strengthening the monitoring and evaluation of community-based IPC interventions.

Table 5.6. Sample methods and approaches to routine monitoring and evaluation of community-based IPC interventions

Methods	Sample approach
Phone polling	Use phone polling to reach a sample of the community members, with the aim of examining attitudes and perceptions around the community-based IPC interventions and gathering feedback around the implementation of existing programmes.
Use social media and digital platforms	Use analytics from various social media and digital platforms to assess the attitudes and perceptions around community-based IPC measures and to identify misconceptions or misinformation hindering compliance.
Focus group discussions	Organise focus group discussions with the members of the community to systematically assess their attitudes and perceptions regarding community-based IPC measures and to identify the factors that hinder high levels of compliance.
Environmental sampling	Regularly collect environmental samples from surfaces and areas in public spaces with high circulation of people to examine the levels of contamination.
Routine data collection	Field questionnaires/surveys to collate self-reported data on compliance. Consider including questions about the frequency of best practices in hand hygiene, mask-wearing and respiratory etiquette; knowledge around best practices; and factors that hinder/promote compliance.
Surveillance systems to track the trends in disease outbreaks	Monitor the number of reported cases for selected infection types and examine the trends over time to take into account the trajectory of local disease outbreaks (e.g. during/aftermath of an outbreak).
Combining data gathered from various sources	Combine data gathered through various methods (e.g. phone polling, surveillance data) to get a more complete picture of the implementation of existing programmes.

Source: OECD review.

5.5.8. Ensuring sustainable funding for community-based IPC programmes

The effective implementation of community-based IPC programmes requires that they receive a consistent and sustainable flow of funds. Yet, the OECD survey revealed that lack of financial resources is among the most important barriers against the implementation of community-based IPC programmes (Figure 5.7). Only 6 out of 24 OECD Members and accession countries reported in the OECD survey that there is a dedicated budget to support the implementation of activities to promote hand hygiene and respiratory etiquette in the community. Lack of sufficient funding was a crucial challenge for community-based activities to promote mask wearing and indoor ventilation, with only 5 and 3 countries reporting to have dedicated funding for these activities.

Figure 5.7. Most OECD Members and accession countries do not allocate a budget to support the implementation of community-based IPC measures

Number of countries that reported currently having a dedicated budget to support the implementation of community-based IPC measures

Note: This graph presents the number of countries that responded to the questions “Is there a dedicated budget to support the implementation of IPC measures in the community (hand hygiene/mask-wearing/respiratory etiquette/indoor ventilation) in the existing national action plan(s) on pandemic preparedness, pandemic influenza or other major infectious diseases with epidemic potential, legislation, policies and/or programmes?”. The list of countries that participated in the survey is provided in Annex Table 5.A.1.

Source: Country self-assessment responding to the 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community.

Countries that consider bolstering the scale up of their community-based IPC programmes can allocate financial resources to these programmes as part of efforts to strengthen the resilience of their health systems to future outbreaks and pandemics.

5.5.9. Build trust in public institutions

The previously discussed policy options can directly impact the level of compliance with community-based IPC measures. In addition to these strategies, the OECD countries can benefit from indirect strategies that can supplement these direct strategies. One vital indirect strategy is to build trust in public institutions. The OECD Trust Framework defines trust as “a person’s belief that another person or institution will act consistently with their expectation of positive behaviour” (OECD, 2017[126]). High levels of trust in public institutions can enhance the level of compliance by offering people the confidence that individuals or institutions will act in accordance with their expectations (Brezzi et al., 2021[127]).

Broadly, the level of trust in public institutions can influence the level of compliance with community-based measures aiming to limit the spread of infections. One recent study with a global focus also showed that trust in the government was correlated with SARS‑CoV‑2 infection and attributable mortality (Bollyky et al., 2022[128]). In OECD, emerging evidence suggests that this finding might be explained by the differences in the levels of compliance between high-trust and low-trust settings. For example, one recent study used data from 17 OECD countries to demonstrate that geographic regions characterised by high levels of trust managed to slow the spread of SARS‑CoV‑2 at a much higher pace compared to low-trust regions (Bargain and Aminjonov, 2020[129]). Higher levels of compliance with measures to limit mobility for non-necessary activities was the main factor that explained the differences in the pace of reduction in SARS‑CoV‑2 infections between high-trust and low-trust regions.

Previous OECD research showed that trust in public institutions can also correlate with perceptions around the level of preparedness for the next pandemic. The 2021 OECD Survey on Drivers of Trust in Public Institutions found that on average, nearly 50% of all respondents across 23 OECD countries expressed confidence that their government would be ready in the event of a future pandemic (OECD, 2022[130]). Importantly, the OECD survey showed that there is an association between the level of trust in the national government and people’s perceptions around pandemic preparedness (Figure 5.8). In general, governments were considered to be better prepared for the next pandemic in countries with greater trust in the national governments.

Figure 5.8. Perceptions around pandemic preparedness and trust in the national government are positively correlated

Share of respondents reporting trust in national government and share of respondents who consider it likely that government institutions will be prepared to protect people’s lives in the event of a future pandemic, 2021

Note: This scatterplot presents the share of “trust” responses to the question “On a scale of 0 to 10, where 0 is not at all and 10 is completely, how much do you trust your national government?”, equal to the values of responses 6‑10 on the response scale, on the y axis. The x axis presents the share of “likely” responses to the question “If a new serious contagious disease spreads, how likely or unlikely do you think is it that government institutions will be prepared to protect people’s lives?”, equal to the values of 6‑10 on the response scale. More information provided at https://www.oecd.org/en/topics/trust-in-government.html.

Source: Based on Figure 4.2. in (OECD, 2022[130]).

Evidence exploring the links between trust in public institutions and community-based IPC measures remains scarce. Yet, recent experiences from OECD countries offer important lessons to create greater trust in public institutions, which in turn can promote greater compliance with community-based IPC measures:

• Increase satisfaction with healthcare services: The 2026 OECD Trust Survey indicates that positive experiences that meet expectations build confidence more broadly in public institutions and uses satisfaction with healthcare services as a signal of changing trust in the health system (OECD, 2026[131]). It finds that trust rose between 2023 and 2025 but remains below 2021 levels: Across the 19 OECD countries with data for all three years, satisfaction among recent users of healthcare services fell from 63% to 55% before recovering to 58% in 2025. Satisfaction has been shown consistently higher among respondents who or whose family members used a health service in the past 12 months (OECD, 2026[131]).

• Use easily accessible, transparent and consistent communication: Prior OECD analyses emphasise the importance of providing easily accessible, clear, concise and consistent messaging in strengthening trust in public institutions (OECD, 2021[132]). During the COVID‑19 pandemic, many OECD countries chose public health communication strategies that emphasised open, transparent and clear communication, coupled with motivational messages as well as expressions of care (OECD, 2020[76]). One recent study that evaluated the impact of New Zealand’s communication strategy during the COVID‑19 pandemic concluded that strategic and transparent public health messaging contributed to building trust with the public institutions at a time of heightened uncertainty and motivated public support for the mitigation measures (e.g. mask wearing, hand hygiene, respiratory etiquette) (Beattie and Priestley, 2021[133]).

• Partner with trusted messengers: Leveraging partnership with trusted public figures (e.g. healthcare professionals, community leaders etc.) can contribute to the credibility and community-wide acceptance of best practices. Trusted public figures are generally perceived as a credible source of information (Merchant, South and Lurie, 2021[134]). When the messages are delivered by trusted individuals, people are more inclined to accept and practise the recommended best practices, leading to greater compliance (Ibid). For example, one recent study argued that in Norway, general practitioners played a key role in disseminating information for strategies to limit the spread of COVID‑19, leading to measurable rises in healthcare institutions, particularly in the public sector (Skirbekk, Magelssen and Conradsen, 2023[135]).

• Get buy-in from community members: Involving the community members in the design and implementation of community-based IPC measures early on is crucial to create a sense of ownership and motivating compliance. This can be particularly important for community-based IPC measures, because they often intend to promote behaviour change at the individual level. For example, one school-based hand hygiene programme in the city of Almería in Spain actively involved the entire school community, including parents and caregivers in its implementation (Azor-Martinez et al., 2021[136]). A study that evaluated the effectiveness of this programme concluded that schools that actively involved the entire school community was more effective in promoting greater levels of hand hygiene compliance compared to schools that only targeted students and school staff.

• Encourage multisectoral co‑operation and collaboration: Multisectoral co‑operation and collaboration can also help boost trust in public institutions by demonstrating a unified front to tackling challenges that have consequences outside of the health sector. As discussed in Section 5.3, community-based IPC measures offer important non-health gains (e.g. reduced school absenteeism), underlining the centrality of multisectoral action. Existing evidence generated primarily through the initiatives in OECD countries suggests that multisectoral collaboration can be boosted through early involvement of non-health stakeholders in the design and implementation of programmes, showcasing the non-health benefits and harmonising the methods and metrics to evaluate the impact of these programmes (Kriegner et al., 2020[137]).

5.6. Conclusions

Community-based IPC measures can help mitigate the spread of viral and bacterial infections, as well as antibiotic resistant infections, while yielding substantial non-health benefits such as lower levels of school absenteeism and greater productivity at work. The COVID‑19 pandemic showcased the centrality of these measures for pandemic preparedness and response, but the existing evidence points to critical gaps in their implementation and low levels of compliance.

The OECD Members and accession countries have in their arsenal a wide range of policies that can be used to motivate greater compliance in the long term. Successful implementation of these policies requires a careful consideration of the unique contextual factors that drive the level of compliance. Establishing regular monitoring and evaluation mechanisms will be key to examine the level of compliance over time and fine‑tune the design features of the existing programmes.

Strengthening the IPC capacity in community settings will require new investments. As the OECD Members and accession countries continue to think through strategies to ensure the resilience of their health systems, community-based IPC measures should be prioritised.

References

[20] Adetokunboh, O. (ed.) (2022), “The impact of heating, ventilation, and air conditioning design features on the transmission of viruses, including the 2019 novel coronavirus: A systematic review of ventilation and coronavirus”, PLOS Global Public Health, Vol. 2/7, p. e0000552, https://doi.org/10.1371/journal.pgph.0000552.

[1] Aiello, A. et al. (2008), “Effect of Hand Hygiene on Infectious Disease Risk in the Community Setting: A Meta-Analysis”, American Journal of Public Health, Vol. 98/8, pp. 1372-1381, https://doi.org/10.2105/ajph.2007.124610.

[61] Allen, J. et al. (2016), “Associations of Cognitive Function Scores with Carbon Dioxide, Ventilation, and Volatile Organic Compound Exposures in Office Workers: A Controlled Exposure Study of Green and Conventional Office Environments”, Environmental Health Perspectives, Vol. 124/6, pp. 805-812, https://doi.org/10.1289/ehp.1510037.

[78] Allington, D. et al. (2020), “Health-protective behaviour, social media usage and conspiracy belief during the COVID-19 public health emergency”, Psychological Medicine, Vol. 51/10, pp. 1763-1769, https://doi.org/10.1017/s003329172000224x.

[31] Arbogast, J. et al. (2016), “Impact of a Comprehensive Workplace Hand Hygiene Program on Employer Health Care Insurance Claims and Costs, Absenteeism, and Employee Perceptions and Practices”, Journal of Occupational and Environmental Medicine, Vol. 58/6, pp. e231-e240, https://doi.org/10.1097/jom.0000000000000738.

[109] Arıkan, D. et al. (2018), “The Effect of Therapeutic Clowning on Handwashing Technique and Microbial Colonization in Preschool Children”, Journal of Nursing Scholarship, Vol. 50/4, pp. 441-450, https://doi.org/10.1111/jnu.12392.

[54] Aslam, M. (ed.) (2021), “A systematic review and meta-analysis of indoor bioaerosols in hospitals: The influence of heating, ventilation, and air conditioning”, PLOS ONE, Vol. 16/12, p. e0259996, https://doi.org/10.1371/journal.pone.0259996.

[68] Atchison, C. et al. (2020), Report 10: Public Response to UK Government Recommendations on COVID-19: Population Survey, 17-18 March 2020, https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-Population-Survey-20-03-2020.pdf (accessed on 6 December 2023).

[136] Azor-Martinez, E. et al. (2021), “Child Care Center Hand Hygiene Programs’ Cost-Effectiveness in Preventing Respiratory Infections”, Pediatrics, Vol. 148/6, https://doi.org/10.1542/peds.2021-052496.

[129] Bargain, O. and U. Aminjonov (2020), “Trust and compliance to public health policies in times of COVID-19”, Journal of Public Economics, Vol. 192, p. 104316, https://doi.org/10.1016/j.jpubeco.2020.104316.

[133] Beattie, A. and R. Priestley (2021), “Fighting COVID-19 with the team of 5 million: Aotearoa New Zealand government communication during the 2020 lockdown”, Social Sciences & Humanities Open, Vol. 4/1, p. 100209, https://doi.org/10.1016/j.ssaho.2021.100209.

[82] Binter, J. et al. (2023), “Predictors and motives for mask-wearing behavior and vaccination intention”, Scientific Reports, Vol. 13/1, https://doi.org/10.1038/s41598-023-37072-6.

[115] Blackwell, C., D. Goya-Tocchetto and Z. Sturman (2017), “Nudges in the Restroom: How Hand-Washing Can Be Impacted by Environmental Cues”, SSRN Electronic Journal, https://doi.org/10.2139/ssrn.3007866.

[128] Bollyky, T. et al. (2022), “Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021”, The Lancet, Vol. 399/10334, pp. 1489-1512, https://doi.org/10.1016/s0140-6736(22)00172-6.

[124] Boruchowicz, C. et al. (2020), Are Behaviorally Informed Text Messages Effective in Promoting Compliance with COVID-19 Preventive Measures?: Evidence from an RCT in the City of São Paulo, Inter-American Development Bank, https://doi.org/10.18235/0002722.

[45] Boutzoukas, A. et al. (2022), “Quarantine Elimination for K–12 Students With Mask-on-Mask Exposure to SARS-CoV-2”, Pediatrics, Vol. 149/Supplement_2, https://doi.org/10.1542/peds.2021-054268l.

[127] Brezzi, M. et al. (2021), “An updated OECD framework on drivers of trust in public institutions to meet current and future challenges”, OECD Working Papers on Public Governance, No. 48, OECD Publishing, Paris, https://doi.org/10.1787/b6c5478c-en.

[72] Brouard, S., P. Vasilopoulos and M. Becher (2020), “Sociodemographic and Psychological Correlates of Compliance with the COVID-19 Public Health Measures in France”, Canadian Journal of Political Science, Vol. 53/2, pp. 253-258, https://doi.org/10.1017/s0008423920000335.

[57] Buonanno, G. et al. (2022), “Increasing ventilation reduces SARS-CoV-2 airborne transmission in schools: A retrospective cohort study in Italy’s Marche region”, Frontiers in Public Health, Vol. 10, https://doi.org/10.3389/fpubh.2022.1087087.

[87] Burgess, A. and M. Horii (2012), “Risk, ritual and health responsibilisation: Japan’s ‘safety blanket’ of surgical face mask-wearing”, Sociology of Health & Illness, Vol. 34/8, pp. 1184-1198, https://doi.org/10.1111/j.1467-9566.2012.01466.x.

[92] CDC (2023), Ventilation in Buildings, https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html (accessed on 4 November 2023).

[51] CDC (2016), Respiratory Hygiene/Cough Etiquette, https://www.cdc.gov/oralhealth/infectioncontrol/faqs/respiratory-hygiene.html (accessed on 23 May 2023).

[18] Chu, D. et al. (2020), “Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis”, The Lancet, Vol. 395/10242, pp. 1973-1987, https://doi.org/10.1016/s0140-6736(20)31142-9.

[93] Conseil de la santé publique, H. (2023), Mesures universelles d’hygiène pour la prévention des principales maladies infectieuses dans la population générale Collection Avis et Rapports, https://www.hcsp.fr/explore.cgi/avisrapportsdomaine?clefr=1289 (accessed on 18 August  2024).

[98] Cradock, A. et al. (2014), “Impact of the Boston Active School Day Policy to Promote Physical Activity among Children”, American Journal of Health Promotion, Vol. 28/3_suppl, pp. S54-S64, https://doi.org/10.4278/ajhp.130430-quan-204.

[5] Department of Health and Social Care (2020), Public information campaign focuses on handwashing, https://www.gov.uk/government/news/public-information-campaign-focuses-on-handwashing#:~:text=Washing%20hands%20for%2020%20seconds,coronavirus%20(COVID%2D19). (accessed on 7 December 2023).

[108] Dingman, D., J. Wu and H. Murphy (2020), “School-based, blacklight handwashing program can improve handwashing quality and knowledge among pre-school aged children”, Evaluation and Program Planning, Vol. 78, p. 101731, https://doi.org/10.1016/j.evalprogplan.2019.101731.

[11] Dunn, K. et al. (2024), “Summary of WHO infection prevention and control guideline for covid-19: striving for evidence based practice in infection prevention and control”, BMJ, p. q645, https://doi.org/10.1136/bmj.q645.

[111] e-Bug Project (2022), KS1/KS2/KS3 Respiratory Hygiene Experiment - Snot Gun Runway, https://www.e-bug.eu/ks2-respiratory-hygiene (accessed on 10 May 2026).

[50] ECDC (2022), Protect yourself against flu: Learn more about preventive measures, https://www.ecdc.europa.eu/en/seasonal-influenza/prevention-and-control/personal-protective-measures (accessed on 23 May 2023).

[27] Ejemot-Nwadiaro, R. (ed.) (2008), Hand washing for preventing diarrhoea, John Wiley & Sons, Ltd, Chichester, UK, https://doi.org/10.1002/14651858.cd004265.pub2.

[25] Ejemot-Nwadiaro, R. et al. (2021), “Hand-washing promotion for preventing diarrhoea”, Cochrane Database of Systematic Reviews, Vol. 2021/1, https://doi.org/10.1002/14651858.cd004265.pub4.

[26] Ejemot-Nwadiaro, R. et al. (2015), “Hand washing promotion for preventing diarrhoea”, Cochrane Database of Systematic Reviews, https://doi.org/10.1002/14651858.cd004265.pub3.

[89] EPA (2022), Clean Air in Buildings Challenge, https://www.epa.gov/system/files/documents/2022-03/508-cleanairbuildings_factsheet_v5_508.pdf (accessed on 3 August 2026).

[34] EuroStat (2022), Employed people usually working from home, 2021 (people aged 20–64, selected NUTS 2 regions), https://ec.europa.eu/eurostat/statistics-explained/index.php?title=File:Employed_people_usually_working_from_home,_2021_(people_aged_20%E2%80%9364,_selected_NUTS_2_regions)_RYB2022.png (accessed on 12 December 2023).

[19] Fang, F. (ed.) (2024), “Masks and respirators for prevention of respiratory infections: a state of the science review”, Clinical Microbiology Reviews, Vol. 37/2, https://doi.org/10.1128/cmr.00124-23.

[12] Ford, E. et al. (2014), “Increasing Hand Washing Compliance With a Simple Visual Cue”, American Journal of Public Health, Vol. 104/10, pp. 1851-1856, https://doi.org/10.2105/ajph.2013.301477.

[64] Freeman, M. et al. (2014), “Systematic review: Hygiene and health: systematic review of handwashing practices worldwide and update of health effects”, Tropical Medicine & International Health, Vol. 19/8, pp. 906-916, https://doi.org/10.1111/tmi.12339.

[58] Gettings, J. et al. (2021), “Mask Use and Ventilation Improvements to Reduce COVID-19 Incidence in Elementary Schools — Georgia, November 16–December 11, 2020”, MMWR. Morbidity and Mortality Weekly Report, Vol. 70/21, pp. 779-784, https://doi.org/10.15585/mmwr.mm7021e1.

[8] Government of the State of Victoria (2023), School operations - Ventilation and Air Purification, https://www2.education.vic.gov.au/pal/ventilation-air-purification/policy (accessed on 19 June 2023).

[13] Gozdzielewska, L. et al. (2022), “The effectiveness of hand hygiene interventions for preventing community transmission or acquisition of novel coronavirus or influenza infections: a systematic review”, BMC Public Health, Vol. 22/1, https://doi.org/10.1186/s12889-022-13667-y.

[55] Haddrell, A. et al. (2024), “Ambient carbon dioxide concentration correlates with SARS-CoV-2 aerostability and infection risk”, Nature Communications, Vol. 15/1, p. 3487, https://doi.org/10.1038/s41467-024-47777-5.

[103] Hanson, C. et al. (2020), “A National Communication Campaign in Indonesia Is Associated with Improved WASH-Related Knowledge and Behaviors in Indonesian Mothers”, International Journal of Environmental Research and Public Health, Vol. 17/10, p. 3727, https://doi.org/10.3390/ijerph17103727.

[65] Haston, J. et al. (2020), “Characteristics Associated with Adults Remembering to Wash Hands in Multiple Situations Before and During the COVID-19 Pandemic — United States, October 2019 and June 2020”, MMWR. Morbidity and Mortality Weekly Report, Vol. 69/40, pp. 1443-1449, https://doi.org/10.15585/mmwr.mm6940a2.

[62] Haverinen-Shaughnessy, U., D. Moschandreas and R. Shaughnessy (2010), “Association between substandard classroom ventilation rates and students’ academic achievement”, Indoor Air, Vol. 21/2, pp. 121-131, https://doi.org/10.1111/j.1600-0668.2010.00686.x.

[118] Heebøll, A., P. Wargocki and J. Toftum (2018), “Window and door opening behavior, carbon dioxide concentration, temperature, and energy use during the heating season in classrooms with different ventilation retrofits - ASHRAE RP1624”, Science and Technology for the Built Environment, Vol. 24/6, pp. 626-637, https://doi.org/10.1080/23744731.2018.1432938.

[37] Hovi, T., J. Ollgren and C. Savolainen-Kopra (2017), “Intensified hand-hygiene campaign including soap-and-water wash may prevent acute infections in office workers, as shown by a recognized-exposure -adjusted analysis of a randomized trial”, BMC Infectious Diseases, Vol. 17/1, https://doi.org/10.1186/s12879-016-2157-z.

[7] Infection Prevention and Control Canada (nd), Coronavirus (COVID-19) Posters, Graphics and Videos, https://ipac-canada.org/posters-graphics-and-videos (accessed on 7 December 2023).

[113] Irish Department of Health (2025), Using Behavioural Science to Improve Hand Hygiene in Workplaces and Public Places, https://www.gov.ie/en/irish-government-economic-and-evaluation-service-igees/igees-publication/using-behavioural-science-to-improve-hand-hygiene-in-workplaces-and-public-places/ (accessed on 3 August 2026).

[14] Jefferson, T. et al. (2023), “Physical interventions to interrupt or reduce the spread of respiratory viruses”, Cochrane Database of Systematic Reviews, Vol. 2023/4, https://doi.org/10.1002/14651858.cd006207.pub6.

[60] Jones, E. et al. (2021), “The effects of ventilation and filtration on indoor PM2.5 in office buildings in four countries”, Building and Environment, Vol. 200, p. 107975, https://doi.org/10.1016/j.buildenv.2021.107975.

[40] Judah, G. et al. (2009), “Dirty hands: bacteria of faecal origin on commuters’ hands”, Epidemiology and Infection, Vol. 138/3, pp. 409-414, https://doi.org/10.1017/s0950268809990641.

[67] Kim, D. et al. (2023), “Support for regulation versus compliance: Face masks during COVID-19”, Public Health in Practice, Vol. 5, p. 100324, https://doi.org/10.1016/j.puhip.2022.100324.

[74] Kim, J. and K. Yoon (2022), “Association among the exposure to giving knowledge, attitude and practice for handwashing in people residing in Seoul, South Korea: a retrospective cross-sectional study”, BMJ Open, Vol. 12/2, p. e053329, https://doi.org/10.1136/bmjopen-2021-053329.

[59] Kitamura, H. et al. (2022), “Ventilation improvement and evaluation of its effectiveness in a Japanese manufacturing factory”, Scientific Reports, Vol. 12/1, https://doi.org/10.1038/s41598-022-22764-2.

[137] Kriegner, S. et al. (2020), “Promoting Intersectoral Collaboration Through the Evaluations of Public Health Interventions: Insights From Key Informants in 6 European Countries”, International Journal of Health Policy and Management, https://doi.org/10.34172/ijhpm.2020.19.

[123] Lee, M. and M. You (2021), “Effects of COVID-19 Emergency Alert Text Messages on Practicing Preventive Behaviors: Cross-sectional Web-Based Survey in South Korea”, Journal of Medical Internet Research, Vol. 23/2, p. e24165, https://doi.org/10.2196/24165.

[83] Li, H. et al. (2022), “Efficacy and practice of facemask use in general population: a systematic review and meta-analysis”, Translational Psychiatry, Vol. 12/1, https://doi.org/10.1038/s41398-022-01814-3.

[9] Lison, A. et al. (2023), “Effectiveness assessment of non-pharmaceutical interventions: lessons learned from the COVID-19 pandemic”, The Lancet Public Health, Vol. 8/4, pp. e311-e317, https://doi.org/10.1016/s2468-2667(23)00046-4.

[88] Li, T. et al. (2023), “Habitual Mask Wearing as Part of COVID-19 Control in Japan: An Assessment Using the Self-Report Habit Index”, Behavioral Sciences, Vol. 13/11, p. 951, https://doi.org/10.3390/bs13110951.

[53] Li, Y. et al. (2007), “Role of ventilation in airborne transmission of infectious agents in the built environment ? a multidisciplinary systematic review”, Indoor Air, Vol. 17/1, pp. 2-18, https://doi.org/10.1111/j.1600-0668.2006.00445.x.

[41] Lutz, J. et al. (2014), “Methicillin-resistant Staphylococcus aureus in public transportation vehicles (buses): Another piece to the epidemiologic puzzle”, American Journal of Infection Control, Vol. 42/12, pp. 1285-1290, https://doi.org/10.1016/j.ajic.2014.08.016.

[125] MacLeod, C. et al. (2023), “Recommendations for hand hygiene in community settings: a scoping review of current international guidelines”, BMJ Open, Vol. 13/6, p. e068887, https://doi.org/10.1136/bmjopen-2022-068887.

[3] Maillard, J. et al. (2020), “Reducing antibiotic prescribing and addressing the global problem of antibiotic resistance by targeted hygiene in the home and everyday life settings: A position paper”, American Journal of Infection Control, Vol. 48/9, pp. 1090-1099, https://doi.org/10.1016/j.ajic.2020.04.011.

[114] McGuckin, M. and J. Govednik (2013), “Patient empowerment and hand hygiene, 1997–2012”, Journal of Hospital Infection, Vol. 84/3, pp. 191-199, https://doi.org/10.1016/j.jhin.2013.01.014.

[71] Meilicke, G. et al. (2013), “Hygiene perception changes during the influenza A H1N1 pandemic in Germany: incorporating the results of two cross-sectional telephone surveys 2008–2009”, BMC Public Health, Vol. 13/1, https://doi.org/10.1186/1471-2458-13-959.

[63] Mendell, M. et al. (2013), “Association of classroom ventilation with reduced illness absence: a prospective study in California elementary schools”, Indoor Air, Vol. 23/6, pp. 515-528, https://doi.org/10.1111/ina.12042.

[134] Merchant, R., E. South and N. Lurie (2021), “Public Health Messaging in an Era of Social Media”, JAMA, Vol. 325/3, p. 223, https://doi.org/10.1001/jama.2020.24514.

[100] Monge-Barrio, A. et al. (2022), “Encouraging natural ventilation to improve indoor environmental conditions at schools. Case studies in the north of Spain before and during COVID”, Energy and Buildings, Vol. 254, p. 111567, https://doi.org/10.1016/j.enbuild.2021.111567.

[79] Mourali, M. and C. Drake (2022), “The Challenge of Debunking Health Misinformation in Dynamic Social Media Conversations: Online Randomized Study of Public Masking During COVID-19”, Journal of Medical Internet Research, Vol. 24/3, p. e34831, https://doi.org/10.2196/34831.

[39] Mo, Y. et al. (2022), “The effect of hand hygiene frequency on reducing acute respiratory infections in the community: a meta-analysis”, Epidemiology and Infection, Vol. 150, https://doi.org/10.1017/s0950268822000516.

[4] Müller, O., O. Razum and A. Jahn (2021), “Effects of non-pharmaceutical interventions against COVID-19 on the incidence of other diseases”, The Lancet Regional Health - Europe, Vol. 6, p. 100139, https://doi.org/10.1016/j.lanepe.2021.100139.

[80] Murakami, M., M. Yamagata and A. Miura (2023), “Exploration of factors associated with mask-wearing and hand disinfection in Japan after the coronavirus disease outbreak: A longitudinal study”, International Journal of Disaster Risk Reduction, Vol. 98, p. 104107, https://doi.org/10.1016/j.ijdrr.2023.104107.

[121] Murray, M. (ed.) (2018), “Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies”, PLOS Medicine, Vol. 15/7, p. e1002595, https://doi.org/10.1371/journal.pmed.1002595.

[85] Nippon Research Center (2023), Voluntary survey on novel coronavirus infections [Japanese], https://www.nrc.co.jp/nryg/230602.html (accessed on 8 August 2023).

[73] Nivette, A. et al. (2021), “Non-compliance with COVID-19-related public health measures among young adults in Switzerland: Insights from a longitudinal cohort study”, Social Science & Medicine, Vol. 268, p. 113370, https://doi.org/10.1016/j.socscimed.2020.113370.

[131] OECD (2026), OECD Survey on Drivers of Trust in Public Institutions 2026 Results: Navigating Rising Expectations and New Horizons, OECD Publishing, Paris, https://doi.org/10.1787/9eb63fec-en.

[22] OECD (2023), Embracing a One Health Framework to Fight Antimicrobial Resistance, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/ce44c755-en.

[130] OECD (2022), Building Trust to Reinforce Democracy: Main Findings from the 2021 OECD Survey on Drivers of Trust in Public Institutions, Building Trust in Public Institutions, OECD Publishing, Paris, https://doi.org/10.1787/b407f99c-en.

[35] OECD (2022), Promoting Health and Well-being at Work: Policy and Practices, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/e179b2a5-en.

[132] OECD (2021), COVID-19 and Well-being: Life in the Pandemic, OECD Publishing, Paris, https://doi.org/10.1787/1e1ecb53-en.

[32] OECD (2021), “Teleworking in the COVID-19 pandemic: Trends and prospects”, OECD Policy Responses to Coronavirus (COVID-19), OECD Publishing, Paris, https://doi.org/10.1787/72a416b6-en.

[76] OECD (2020), “Transparency, communication and trust: The role of public communication in responding to the wave of disinformation about the new Coronavirus”, OECD Policy Responses to Coronavirus (COVID-19), OECD Publishing, Paris, https://doi.org/10.1787/bef7ad6e-en.

[126] OECD (2017), OECD Guidelines on Measuring Trust, OECD Publishing, Paris, https://doi.org/10.1787/9789264278219-en.

[122] Orr, J. and R. King (2015), “Mobile phone SMS messages can enhance healthy behaviour: a meta-analysis of randomised controlled trials”, Health Psychology Review, Vol. 9/4, pp. 397-416, https://doi.org/10.1080/17437199.2015.1022847.

[70] Park, J. et al. (2010), “Perceptions and behaviors related to hand hygiene for the prevention of H1N1 influenza transmission among Korean university students during the peak pandemic period”, BMC Infectious Diseases, Vol. 10/1, https://doi.org/10.1186/1471-2334-10-222.

[107] Parveen, S. et al. (2022), “Public Health Interventions to Improve Antimicrobial Resistance Awareness and Behavioural Change Associated with Antimicrobial Use: A Systematic Review Exploring the Use of Social Media”, Antibiotics, Vol. 11/5, p. 669, https://doi.org/10.3390/antibiotics11050669.

[77] Pavela Banai, I., B. Banai and I. Mikloušić (2021), “Beliefs in COVID-19 conspiracy theories, compliance with the preventive measures, and trust in government medical officials”, Current Psychology, Vol. 41/10, pp. 7448-7458, https://doi.org/10.1007/s12144-021-01898-y.

[10] Persad, G. and A. Pandya (2022), “A Comprehensive Covid-19 Response - The Need for Economic Evaluation”, New England Journal of Medicine, Vol. 386/26, pp. 2449-2451, https://doi.org/10.1056/nejmp2202828.

[33] PRC (2023), About a third of U.S. workers who can work from home now do so all the time, https://www.pewresearch.org/short-reads/2023/03/30/about-a-third-of-us-workers-who-can-work-from-home-do-so-all-the-time/ (accessed on 12 December 2023).

[106] Price, L. et al. (2018), “Effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review”, Journal of Antimicrobial Chemotherapy, Vol. 73/6, pp. 1464-1478, https://doi.org/10.1093/jac/dky076.

[15] Rabie, T. and V. Curtis (2006), “Handwashing and risk of respiratory infections: a quantitative systematic review”, Tropical Medicine & International Health, Vol. 11/3, pp. 258-267, https://doi.org/10.1111/j.1365-3156.2006.01568.x.

[23] Randle, J. et al. (2013), “Impact of an educational intervention upon the hand hygiene compliance of children”, Journal of Hospital Infection, Vol. 85/3, pp. 220-225, https://doi.org/10.1016/j.jhin.2013.07.013.

[117] Rawat, N. et al. (2025), “Improving classroom air quality and ventilation with IoT-driven acoustic and visual CO2 feedback system”, Science of The Total Environment, Vol. 980, p. 179543, https://doi.org/10.1016/j.scitotenv.2025.179543.

[75] Read, B. et al. (2022), “Comparing public knowledge around value of hand and respiratory hygiene, vaccination, and pre- and post-national COVID-19 lockdown in England”, Public Health, Vol. 212, pp. 76-83, https://doi.org/10.1016/j.puhe.2022.08.015.

[16] Saokaew, S. (ed.) (2022), “Face masks to prevent transmission of respiratory infections: Systematic review and meta-analysis of randomized controlled trials on face mask use”, PLOS ONE, Vol. 17/12, p. e0271517, https://doi.org/10.1371/journal.pone.0271517.

[48] Saunders-Hastings, P. et al. (2017), “Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis”, Epidemics, Vol. 20, pp. 1-20, https://doi.org/10.1016/j.epidem.2017.04.003.

[104] Scott, B. et al. (2008), “Marketing hygiene behaviours: the impact of different communication channels on reported handwashing behaviour of women in Ghana”, Health Education Research, Vol. 23/3, pp. 392-401, https://doi.org/10.1093/her/cym056.

[120] Scott-Sheldon, L. et al. (2016), “Text Messaging-Based Interventions for Smoking Cessation: A Systematic Review and Meta-Analysis”, JMIR mHealth and uHealth, Vol. 4/2, p. e49, https://doi.org/10.2196/mhealth.5436.

[99] Semenza, J. and S. Paz (2021), “Climate change and infectious disease in Europe: Impact, projection and adaptation”, The Lancet Regional Health - Europe, Vol. 9, p. 100230, https://doi.org/10.1016/j.lanepe.2021.100230.

[90] Service public fédéral Santé publique (2022), Adoption de la loi sur la Qualité de l’air Intérieur, https://www.health.belgium.be/fr/news/adoption-de-la-loi-sur-la-qualite-de-lair-interieur.

[6] Service-Public (2023), Covid-19 : quelles règles de prise en charge ?, https://www.service-public.fr/particuliers/vosdroits/F35262#:~:text=Les%20personnes%20suivantes%20peuvent%20b%C3%A9n%C3%A9ficier,les%20masques%20par%20la%20Poste. (accessed on 6 November 2023).

[135] Skirbekk, H., M. Magelssen and S. Conradsen (2023), “Trust in healthcare before and during the COVID-19 pandemic”, BMC Public Health, Vol. 23/1, https://doi.org/10.1186/s12889-023-15716-6.

[66] Spira, B. (2022), “Correlation Between Mask Compliance and COVID-19 Outcomes in Europe”, Cureus, https://doi.org/10.7759/cureus.24268.

[101] Stabile, L. et al. (2019), “The Effect of Ventilation Strategies on Indoor Air Quality and Energy Consumptions in Classrooms”, Buildings, Vol. 9/5, p. 110, https://doi.org/10.3390/buildings9050110.

[2] Suess, T. et al. (2012), “The role of facemasks and hand hygiene in the prevention of influenza transmission in households: results from a cluster randomised trial; Berlin, Germany, 2009-2011”, BMC Infectious Diseases, Vol. 12/1, https://doi.org/10.1186/1471-2334-12-26.

[69] Szczuka, Z. et al. (2021), “The trajectory of COVID-19 pandemic and handwashing adherence: findings from 14 countries”, BMC Public Health, Vol. 21/1, https://doi.org/10.1186/s12889-021-11822-5.

[84] Teasdale, E. et al. (2014), “Public perceptions of non-pharmaceutical interventions for reducing transmission of respiratory infection: Systematic review and synthesis of qualitative studies”, BMC Public Health, Vol. 14/1, https://doi.org/10.1186/1471-2458-14-589.

[112] Thompson, S. and L. Rew (2015), “The Healthy Workplace Project: Results of a Hygiene-Based Approach to Employee Wellness”, American Journal of Health Promotion, Vol. 29/5, pp. 339-341, https://doi.org/10.4278/ajhp.130830-ARB-459.

[105] Tidwell, J. et al. (2019), “Effect of Two Complementary Mass-Scale Media Interventions on Handwashing with Soap among Mothers”, Journal of Health Communication, Vol. 24/2, pp. 203-215, https://doi.org/10.1080/10810730.2019.1593554.

[94] van Beeck, A. et al. (2015), “Children’s hand hygiene behaviour and available facilities: an observational study in Dutch day care centres”, The European Journal of Public Health, Vol. 26/2, pp. 297-300, https://doi.org/10.1093/eurpub/ckv228.

[28] Veys, K. et al. (2021), “The effect of hand hygiene promotion programs during epidemics and pandemics of respiratory droplet-transmissible infections on health outcomes: a rapid systematic review”, BMC Public Health, Vol. 21/1, https://doi.org/10.1186/s12889-021-11815-4.

[24] Viboud, C. (2004), “Risk factors of influenza transmission in households.”, The British journal of general practice: the journal of the Royal College of General Practitioners., Vol. 54/506, pp. 684–689, https://bjgp.org/content/54/506/684.long (accessed on 22 May 2023).

[86] Wada, K., K. Oka-Ezoe and D. Smith (2012), “Wearing face masks in public during the influenza season may reflect other positive hygiene practices in Japan”, BMC Public Health, Vol. 12/1, https://doi.org/10.1186/1471-2458-12-1065.

[30] Wang, Z. et al. (2017), “The effect of hand-hygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review”, American Journal of Infection Control, Vol. 45/6, pp. 682-689, https://doi.org/10.1016/j.ajic.2017.01.018.

[116] Wargocki, P. and N. Da Silva (2014), “Use of visual CO₂feedback as a retrofit solution for improving classroom air quality”, Indoor Air, Vol. 25/1, pp. 105-114, https://doi.org/10.1111/ina.12119.

[38] Warren-Gash, C., E. Fragaszy and A. Hayward (2012), “Hand hygiene to reduce community transmission of influenza and acute respiratory tract infection: a systematic review”, Influenza and Other Respiratory Viruses, Vol. 7/5, pp. 738-749, https://doi.org/10.1111/irv.12015.

[42] WHO (2023), Infection prevention and control in the context of coronavirus disease (COVID-19): a living guideline, 13 January 2023., https://www.who.int/publications/i/item/WHO-2019-nCoV-ipc-guideline-2023.1 (accessed on 30 May 2023).

[44] WHO (2023), Infection prevention and control in the context of COVID-19: a guideline, 21 December 2023, https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-guideline-2023.4 (accessed on 8 May 2026).

[56] WHO (2021), Coronavirus disease (COVID-19): Ventilation and air conditioning, https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-covid-19-ventilation-and-air-conditioning (accessed on 14 August 2023).

[43] WHO (2021), COVID-19 infection prevention and control living guideline: mask use in community settings, 22 December 2021, https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC_Masks-2021.1 (accessed on 8 May  2026).

[47] WHO (2021), Infection preventioon and control during health care when coronavirus disease (COVID-19) is suspected or confirmed, https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-2021.1 (accessed on 16 May 2023).

[52] WHO (2021), Roadmap to improve and ensure good indoor ventilation in the context of COVID-19, https://apps.who.int/iris/bitstream/handle/10665/339857/9789240021280-eng.pdf (accessed on 2 June 2023).

[91] WHO (2020), Recommendations to Member States to improve hand hygiene practices to help prevent the transmission of the COVID-19 virus, https://www.who.int/publications/i/item/recommendations-to-member-states-to-improve-hand-hygiene-practices-to-help-prevent-the-transmission-of-the-covid-19-virus (accessed on 3 May 2023).

[119] WHO (2020), WHO COVID-19 message library, https://www.who.int/publications/i/item/covid-19-message-library (accessed on 10 December 2023).

[49] WHO (2019), Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza., https://apps.who.int/iris/bitstream/handle/10665/329438/9789241516839-eng.pdf (accessed on 15 May 2023).

[29] Willmott, M. et al. (2015), “Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: a systematic review and meta-analysis”, Archives of Disease in Childhood, Vol. 101/1, pp. 42-50, https://doi.org/10.1136/archdischild-2015-308875.

[95] Wilson, N. and G. Thomson (2021), “Deficient handwashing amenities in public toilets in the time of the COVID-19 pandemic: a multi-regional survey”, New Zealand Medical Journal, Vol. 134/1537, pp. 18-27.

[81] Wise, T. et al. (2020), “Changes in risk perception and self-reported protective behaviour during the first week of the COVID-19 pandemic in the United States”, Royal Society Open Science, Vol. 7/9, p. 200742, https://doi.org/10.1098/rsos.200742.

[21] Wißmann, J. et al. (2021), “Persistence of Pathogens on Inanimate Surfaces: A Narrative Review”, Microorganisms, Vol. 9/2, p. 343, https://doi.org/10.3390/microorganisms9020343.

[46] Wood, M. et al. (2018), “Face Masks and Cough Etiquette Reduce the Cough Aerosol Concentration of <i>Pseudomonas aeruginosa</i> in People with Cystic Fibrosis”, American Journal of Respiratory and Critical Care Medicine, Vol. 197/3, pp. 348-355, https://doi.org/10.1164/rccm.201707-1457oc.

[17] Xiao, J. et al. (2020), “Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings—Personal Protective and Environmental Measures”, Emerging Infectious Diseases, Vol. 26/5, pp. 967-975, https://doi.org/10.3201/eid2605.190994.

[96] Yoshikawa, Y. et al. (2021), “Financial strategies targeting healthcare providers to promote the prudent use of antibiotics: a systematic review of the evidence”, International Journal of Antimicrobial Agents, Vol. 58/6, p. 106446, https://doi.org/10.1016/j.ijantimicag.2021.106446.

[110] Younie, S. et al. (2020), “Improving young children’s handwashing behaviour and understanding of germs: The impact of A Germ’s Journey educational resources in schools and public spaces”, PLOS ONE, Vol. 15/11, p. e0242134, https://doi.org/10.1371/journal.pone.0242134.

[102] Yousuf, H. et al. (2020), “Association of a Public Health Campaign About Coronavirus Disease 2019 Promoted by News Media and a Social Influencer With Self-reported Personal Hygiene and Physical Distancing in the Netherlands”, JAMA Network Open, Vol. 3/7, p. e2014323, https://doi.org/10.1001/jamanetworkopen.2020.14323.

[36] Zivich, P., A. Gancz and A. Aiello (2018), “Effect of hand hygiene on infectious diseases in the office workplace: A systematic review”, American Journal of Infection Control, Vol. 46/4, pp. 448-455, https://doi.org/10.1016/j.ajic.2017.10.006.

[97] Zukowska, D. et al. (2020), “Ventilation in low energy residences – a survey on code requirements, implementation barriers and operational challenges from seven European countries”, International Journal of Ventilation, Vol. 20/2, pp. 83-102, https://doi.org/10.1080/14733315.2020.1732056.

Annex 5.A. List of countries participated in the 2023-2024 OECD Survey on Maintaining Infection Prevention and Control in the Community

Annex Table 5.A.1. Countries participating in the 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community, as of 3 April 2024

Country	Participation in the policy survey
Australia	Participated
Austria	Participated
Belgium	Did not participate
Canada	Participated
Chile	Did not participate
Costa Rica	Did not participate
Colombia	Participated
Czechia	Did not participate
Denmark	Did not participate
Estonia	Did not participate
Finland	Did not participate
France	Participated
Germany	Participated
Greece	Participated
Hungary	Did not participate
Iceland	Did not participate
Ireland	Did not participate
Israel	Participated
Italy	Participated
Japan	Participated
Korea	Did not participate
Latvia	Participated
Lithuania	Participated
Luxembourg	Participated
Mexico	Did not participate
Netherlands	Did not participate
New Zealand	Participated
Norway	Participated
Poland	Participated
Portugal	Did not participate
Slovak Republic	Participated
Slovenia	Participated
Spain	Participated
Sweden	Did not participate
Switzerland	Participated
Türkiye	Did not participate
United Kingdom	Participated
United States	Participated
Bulgaria	Participated
Brazil	Did not participate
Croatia	Participated
Peru	Did not participate
Romania	Did not participate

Annex 5.B. Community-based IPC Implementation Dashboard

Annex Table 5.B.1. Dashboard on the implementation of policy options to promote community-based IPC programmes in OECD Member and Accession countries

Panel A	Improving Hand Hygiene
OECD Member countries and Accession countries	Free‑of-charge handwashing materials	Mass media campaigns		Educational activities targeting the community		Free‑of-charge informational materials	Visual cues		Text reminders		Free‑of-charge phone lines/websites		Engage with relevant stakeholders and empower local communities		Involve independent experts, scientists, and credible public figures
Australia
Austria
Canada
Colombia
France
Germany
Greece
Israel
Italy
Japan
Latvia
Lithuania
Luxembourg
New Zealand
Norway
Poland
Slovak Republic
Slovenia
Spain
Switzerland
United Kingdom
United States
Bulgaria
Croatia
Panel B	Mask wearing practices
OECD Member countries and Accession countries	Free‑of-charge masks/face coverings	Mass media campaigns		Educational activities targeting the community		Free‑of-charge informational materials	Visual cues		Text reminders		Free‑of-charge phone lines/websites		Engage with relevant stakeholders and empower local communities		Involve independent experts, scientists, and credible public figures
Australia
Austria
Canada
Colombia
France
Germany
Greece
Israel
Italy
Japan
Latvia
Lithuania
Luxembourg
New Zealand
Norway
Poland
Slovak Republic
Slovenia
Spain
Switzerland
United Kingdom
United States
Bulgaria
Croatia
Panel C	Respiratory etiquette
OECD Member countries and Accession countries	Promote cashless/contactless payment systems in stores		Mass media campaigns		Educational activities targeting the community		Visual cues	Text reminders		Free‑of-charge phone lines/websites			Engage with relevant stakeholders and empower local communities		Involve independent experts, scientists, and credible public figures
Australia
Austria
Canada
Colombia
France
Germany
Greece
Israel
Italy
Japan
Latvia
Lithuania
Luxembourg
New Zealand
Norway
Poland
Slovak Republic
Slovenia
Spain
Switzerland
United Kingdom
United States
Bulgaria
Croatia
Panel D	Indoor ventilation
OECD Member countries and Accession countries	Distribute free of charge portable air filters, including HEPA filters		Financial incentives to promote the purchase of portable air filters, including HEPA filters		Encourage natural ventilation in indoor spaces		Encourage regular maintenance and/or redesign of mechanical ventilation systems in public and private buildings		Develop guidelines and recommendations focussing on best practices in indoor ventilation			Engage with relevant stakeholders and empower local communities		Involve independent experts, scientists, and credible public figures
Australia
Austria
Canada
Colombia
France
Germany
Greece
Israel
Italy
Japan
Latvia
Lithuania
Luxembourg
New Zealand
Norway
Poland
Slovak Republic
Slovenia
Spain
Switzerland
United Kingdom
United States
Bulgaria
Croatia

Note: HEPA = High efficiency particulate air.

No plans for implementation

Activities/programmes were implemented at the regional/sub-national level

Activities/programmes were implemented at the national level

Implementation of activities/programmes at national level were fine-tuned/modified based on monitoring and evaluation activities

Unsure/Other

No answer

Source: Country self-assessment responding to the 2023‑2024 OECD survey on Maintaining Infection Prevention and Control Measures in the Community.

Annex 5.C. List of influenza pandemic preparedness plans from G7 countries included in the OECD analysis

Annex Table 5.C.1. List of national influenza pandemic preparedness plans reviewed by the OECD

Country	Pandemic preparedness plan
Canada*	Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector
France	Plan national de prévention et de lutte "Pandémie grippale" 2011 Recommandations Sanitaires Generales Dans Le Cadre De La Lutte Contre Les Maladies Respiratoires Hivernales Et Le Covid-19
Germany	Nationaler Pandemieplan Teil I Strukturen und Maßnahmen Wissenschaftlicher Teil des Nationalen Influenza-Pandemieplans (Teil II)
Italy	Italy 2020 Piano strategico-operativo nazionale di preparazione e risposta a una pandemia influenzale (PanFlu) 2021-2023
Japan	新型インフルエンザ等対策政府行動計画
United Kingdom	UK Influenza Pandemic Preparedness Strategy 2011
United States	National Strategy for Pandemic Influenza Implementation Plan

Note: *The Public Health Agency of Canada has been developing Canada’s Pandemic Preparedness Plan 2026-2027 to ensure the country is ready to respond to future pandemics. The plan is being produced in collaboration with provinces and territories; First Nations, Inuit and Métis partners and pandemic preparedness experts. It sets out a flexible framework and a harmonised approach to pandemic preparedness across the federal, provincial and territorial health sector. It concentrates on respiratory pathogens with pandemic potential. Canada reports that the technical components of the plan, which will become available throughout 2027, will be closely linked to the World Health Organization’s Preparedness and Resilience for Emerging Threats framework, with five components: Emergency Co‑ordination, Collaborative Surveillance, Community Protection, Clinical Care, and Access to Countermeasures.

Notes

← 1.  In this chapter, community settings include households, public settings (e.g. schools, public transport) and private settings and exclude settings where healthcare is routinely delivered (e.g. healthcare centres, clinics and hospitals). Long-term care facilities are also excluded.

← 2.  Respiratory etiquette refers to the practice of covering one’s mouth and nose when sneezing or using a tissue or elbow after sneezing.

← 3.  Asymptomatic infection refers to an infection in which the infected person does not develop symptoms, despite being infected and often capable of transmitting the pathogen.

← 4.  Presymptomatic infection refers to an infection in a person who will go on to develop symptoms, observed during the interval between acquisition of the pathogen and the onset of those symptoms.

← 5.  Sub-clinical infection refers to an infection that does not produce illness recognisable on clinical examination either because signs are absent or because they are too mild or atypical to meet a clinical case definition.