South Africa is currently in week seven of one of the strictest lockdowns globally. The response by the South African government in March 2020 to the Covid-19 pandemic was guided by science and extensive consultation, and it was communicated clearly, empathically and was well supported by most South Africans. The public face of this was infectious disease, public health and clinical medicine specialists.
Compared to the response of the Donald Trump administration where the lessons of science were routinely downplayed and scientists scapegoated, the South African response was impeccable. Communication from the Minister of Health, Dr Zweli Mkhize and Professor Salim Abdool Karim, and other experts was clear, factual, provided up-to-date information about the virus, and outlined what could be done to stop or minimise transmission.
This role of these experts is key, and of course, must continue. However, we are now in a different situation than when we went into lockdown in March. After six weeks of lockdown, community transmission is increasing, with projections of anything up to 3,000 new infections per day by the end of August 2020.
While the lockdown has allowed the health system to better prepare itself, and to increase public education on how to limit transmission and prevent infections, are we changing our behaviour to ensure adherence to these prevention measures? Are environments designed to make it easier for people to follow prevention strategies?
In 1919, following the Spanish flu epidemic, with the global deaths of 50 million people, a paper in the journal Science (Soper, G. A. The lessons of the pandemic. Science 49, 501–506, 1919) concluded that: people do not always appreciate the risks they run; rigid isolation as a way of protecting people went against human nature; and that unknowingly, people acted in ways that endangered themselves and others.
Since then, what have we learned about changing behaviour? It turns out that behavioural scientists and experts know a great deal about this, and it is imperative that they move to be at the forefront of the government response.
Perhaps the most important lesson is that changing behaviour is extremely complex and difficult – even when personal risk is involved. For example, in the US (and a similar figure pertains elsewhere), over 70% of all illness and deaths can be linked in some way to five behaviours – smoking, alcohol, what food is eaten, how much food is eaten, and exercise (de Vol, R. & Bedrosian, A. 2007. An unhealthy America: The economic burden of chronic disease. Los Angeles, CA: The Milken Institute).
These are all behaviours that are to some extent modifiable and amenable to change (some more than others, of course). Yet countless people know how difficult it is to stop smoking, reduce their intake of alcohol, stick to a diet for more than a few weeks, eat healthy foods or to exercise frequently.
A crucial lesson has been that successful behaviour change requires more than just information. While information is key to improving knowledge, changing behaviour requires something more. One example of how information/knowledge moves to actual behaviour change is role modelling. President Cyril Ramaphosa, wearing a mask, clumsily getting it wrong in an empathic, humorous and human way, while physically distancing publicly are all key components of successful behaviour change.
Another illustration is the common method of receiving health information via social media or by text message. We know that people like receiving messages this way and the broad reach of the technology is key. However, the evidence also suggests that the use of passive social media messages (i.e only providing information) should be discouraged. When we use available technologies to ensure that messages received are rich in information, sent at times where uptake is most likely, and where some active engagement between those sending and receiving messages is possible, the likelihood of success increases.
Perhaps the most important lesson from other epidemics (such as Ebola) was how important involving the public in the decision-making process is. This is, of course, related to trust, but if people, local leaders, faith and civic society leaders are involved in the decision-making process, adherence will improve.
We know that one way to improve adherence is through door-to-door outreach. Currently, most of the outreach that is happening is about testing. However, increasing numbers of people are refusing testing (as high as 30% in Soweto), because they fear being forced to self-isolate.
South Africa has tens of thousands of community health workers, a ubiquitous and well-respected workforce. We argue that they would be better deployed going door to door to hand out masks, educate households about hand washing, problem-solve ways to protect elderly family members, and to build the necessary trust so that people will seek out testing voluntarily.
We also know that when there is trust in government there is a greater likelihood of people adopting recommendations. Linked to this is the importance of open communication and acknowledging uncertainty. It is now widely acknowledged that Singapore’s experience and success during the SARS epidemic was due in large part to transparency in communication.
The Singapore government was able to build conﬁdence and trust with a transparent approach to communications that fully acknowledged uncertainty, thus allowing policy shifts and changes as the epidemic evolved.
Behavioural science also shows us how quickly trust can dissipate. Of particular resonance for South Africa right now is the issue of coercion and instances of military and police overreach. The more people are threatened and coerced as a way of trying to get them to comply, the more likely they are to feel that their trust in the government and the government’s trust in them has been breached. Paradoxically, what then happens is that people drastically reduce their willingness to follow directives.
Another lesson we have learned about behaviour change has come from the field of behavioural economics. Nobel Laureate Richard Thaler and his colleague Cass Sunstein popularised the concept of “nudge” in their book Nudge: Improving decision about health, wealth and happiness.
Nudging is a way of redesigning environments (also known as modifying choice architecture), which assists in the process of aligning people’s immediate choices with what they have rationally decided to do, but may be finding difficult to always remember and act on.
Importantly, nudges are subtle, do not involve outright persuasion and certainly do not involve bans or legislative regulation. Paradoxically, people should be easily able to avoid a nudge. Putting fruit at eye level, for example, to increase fruit consumption counts as a nudge. Taxing sugar to reduce consumption is not a nudge.
Examples of nudges in the current pandemic would be to place large pictures of the coronavirus throughout public toilets to encourage hand washing, placing alcohol-based hand sanitisers where they are visible as well as markers on the floor to assist with physical distancing. In essence, nudging is about creating enabling environments to help change behaviour.
In a pandemic, fear and anxiety are, of course, predominant emotions for many. Fear and anxiety are not emotions that allow people to (necessarily) rationally and logically plan their responses and behaviours in ways that we as public health practitioners would like.
The Nobel Laureate Daniel Kahneman has developed a two-system theory for how people process information. In the first system (Thinking Fast), processing is automatic, fast and highly susceptible to influences from the environment. In system 2 (Thinking Slow), processing is more reflective, much slower and takes into account goals and intentions (Daniel Kahneman, Thinking Fast and Slow, Farrar, Straus and Giroux, 2011).
If we believe that what happens in planning a response to a pandemic or anything, is that people hear information, then rationally and logically plan their behavioural response, we are missing perhaps the largest piece in the puzzle. In fact, a big part may be instinctive, automatic and unconscious. This was clearly seen in some initial responses to the pandemic when people began hoarding face masks.
Our safety in this pandemic is as dependent (if not more) on everybody else wearing masks as it is on us having enough masks for ourselves and our families. But the environmental cues that people were receiving were about danger, panic and there not being enough masks resulting in a rush to buy face masks. Behavioural science has shown us when people are fearful and anxious, they will act to achieve a measure of control and safety, and may do this quite rationally and logically. But if they continue to feel scared and helpless, they may well respond with defensiveness or anger.
Finally, the “Behaviour Change Wheel” is a way of understanding how behaviour can be changed. It consists of three elements. Firstly, individuals must be able to undertake the behaviour (if you have no access to soap, water and/or sanitiser), you will not be able to wash your hands. Secondly, the environment has to facilitate the required behaviour (self-isolating in a one-roomed shack shared by six people is completely impossible). Finally, people must be confident that they can make the required changes (have a sense of agency and self-efficacy in the world).
The extreme poverty and inequality that characterises South Africa massively impacts on whether people are able to, in fact, act on recommendations.
The Covid-19 response to the pandemic by the South African government has been excellent thus far – role modelling strong, rational, evidence-informed, empathic and coherent leadership. This can be boosted with active engagement and involvement of behavioural scientists in the implementation of the response. A leadership that says we responded, we have learned and we are adapting our response to a transdisciplinary approach to ensure we do everything we can to respond to the pandemic. DM
Professor Mark Tomlinson is a clinical psychologist by training and is currently the Co-Director of the Institute for Life Course Health Research at Stellenbosch University.
Professor Taryn Young is a public health specialist with a passion for enhancing the uptake and use of research evidence in healthcare policy and practice.
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