Since Covid-19 was declared a pandemic early in 2020, there has been a consistent message for Covid-19 prevention: wear your mask, make sure you physically distance and ensure good hand hygiene. Despite the development and roll-out of the vaccine in many countries such as the US and the UK, the behavioural messages are the same, although they are now more commonly being referred to as “non-pharmacological measures”.

Needless to say, medical specialists and key individuals on task teams and advisory committees in South Africa and around the world are the conveyers of the behavioural messaging to reduce the burden of the pandemic. With due respect to these highly reputable scientists, infectious disease specialists, public health physicians, presidents, ministers, and the like, there has been a conspicuous absence of behavioural medicine specialists in the media space and serving on “important task teams”.

Perhaps those of us who are behavioural medicine specialists have ourselves to blame for allowing the biomedical model to dominate once again and for allowing the use of the term “non-pharmacological interventions” to proliferate as a smokescreen for what are in fact behavioural interventions.

As a behavioural medicine and public health specialist, I decided to put pen to paper. The reasons for this are two-fold:

1. To call attention to the importance of the inclusion of all relevant specialists as part of a multi-disciplinary high-level task team for positive impact on health outcomes, more so during a pandemic that’s ravaging the world; and
2. To call attention to the fact that despite being told by some of the best and most trusted scientific minds in the world to heed the mask-wearing, physical distancing and good hand hygiene regimes, a large section of the population both here and abroad choose to ignore and refuse to adopt this “basket” of behavioural public health interventions.

I urge the ministerial committees and subcommittees for Covid-19 to include behavioural medicine specialists in their teams, albeit a request that is a trifle late. It has been clear from reports in South Africa and globally that many individuals have an “optimistic bias”, believing that they will not be infected by Covid-19 as it only affects “the other” where the other is perceived to be the downtrodden and disenfranchised individuals of low socioeconomic standing.

Clearly, the chosen spokespersons in South Africa and beyond are not making a big enough impact at population level through the knowledge they are disseminating to the public. The population-level effect is key to behaviour change that’s tangible and can be measured by a key indicator, namely trends in the positivity rate.

It’s not that simple, of course, but there is sufficient evidence to show that mask-wearing, physical distancing and good hand hygiene lead to positive health outcomes (a decrease in the rate of virus transmission). In South Africa, many of us have the experience and expertise of the disease trajectory of HIV, Aids and TB. Moreover, the development of the vaccines for Covid-19 prevention, while a scientific feat, might be rendered useless unless there is uptake by the target groups. We know too well that knowledge does not automatically lead to the adoption of healthy behaviours. Behavioural medicine specialists have a key role to play. I rest my case on this issue.

The second issue of concern is very complex and therefore requires a more complex strategy. Many individuals do not adhere to the recommended behavioural guidelines for Covid-19 prevention: wear a mask, keep socially distant, maintain good hygiene, avoid indoor and outdoor gatherings and other “non-pharmacological interventions”.

Drawing from my own knowledge base, emerging evidence and deep observations, it does appear to be that non-adherent behaviour is associated with many intersecting factors including those at an individual level; family/community level; and societal/environmental level. It’s beyond the scope of this article to address each of these levels to the depth that would be ideal. It is important, however, to get some perspective.

At an individual level, one’s value system and personality drive decisions. If one has a deep respect and regard for others and you’re equipped with the knowledge of how Covid-19 spreads, then there’s an increased chance that individuals will follow through on recommendations. If individuals are easily swayed by populist-level influencers and significant others in their social network by ingesting misinformation that the disease, for example, is a “hoax” or only affects the “poor” this may lead to non-adherence to Covid-19 prevention. Deeply held beliefs that this is a “black African” problem touches the nerve of structural racism.

On the flip side, there are many disenfranchised individuals who believe that the viciousness of Covid-19 is being exaggerated, hence they fail to, for example, wear their masks in public spaces or while using public transport. Individuals with rigid personalities perhaps pose the greatest risk as their inflexibility does not allow them to process new knowledge in a meaningful way.

At a family or community level, facts and non-facts are circulating and percolating. Individuals, families and communities who rely on hearsay and unreliable sources of information via faith-based structures, social networks or print and other media about the routes of transmission of Covid-19 and prevention measures are more likely to contribute (often unknowingly) to community spread as they tend to adopt a “fatalistic” attitude. In families and communities in which selected individuals take on leadership roles, equip themselves with the facts, and lead by example, one can expect that the community spread will be slower.

At a societal or environmental level, the factors that influence the adherence to the protocols for Covid-19 are both overt and covert. Influencers include government structures, places of work and business, global politics and economics. Often these various agencies convey mixed messages about the Covid-19 disease trajectory, communities that are affected, disaggregated data for age and sex, co-morbidities and multi-morbidities and so on.

A lack of transparency often characterises public appearances by health authorities and other government structures. The public appearances by appointed spokespersons providing updates on Covid-19 lack the detail that has the potential to decrease the devastation from the social and economic fallout from the pandemic. It often fails to provide the knowledge and education needed by the public about “transmittable/communicable diseases” and also about how non-communicable diseases, such as diabetes, heart disease, strokes, cancer, hypertension and mental health collide, resulting in worse health outcomes, often in death.

The Covid-19 pandemic has brought out the best and the worst in individuals, government structures and other agencies. What underpins much of the chaos and the goodness is human behaviour. Let’s mobilise for the inclusion of behavioural medicine and indeed other relevant specialists such as health economists on the committees that have been formed to move the public health dial during the time of the pandemic and beyond.

Moreover, a solid and well thought-through plan needs to be developed before the vaccine rollout. Resistance to the uptake of the vaccine may arise out of distrust of the vaccine manufacturer or the country in which the vaccine was developed. The government, therefore, has to be open and transparent about the characteristics of all the available vaccines. In particular, information about vaccine efficacy and possible side-effects should be readily available so that members of the public can make an informed decision about consenting (or not) to take the vaccine.

During this pandemic period, the importance of direct and honest communication as one of the conduits to facilitate adherence to the recommended behavioural interventions for Covid-19 prevention has become apparent. Let’s use our behavioural medicine specialists as a critical cog in the wheel of the multidisciplinary health team to reduce the burden of the pandemic by influencing the uptake of healthy behaviours. DM

Prof Pamela Naidoo (MA Clin Psych, MPH, DPhil) is CEO of the Heart and Stroke Foundation South Africa.