Infusing behavioral insights in COVID-19 communication strategies to improve public health compliance
22 July 2020
15-minute read for policy-makers, government officials, company executives, communications and human resources teams, and problem-solvers*
Why an evidence-based communication strategy is a game-changer
In a message directed to global and national leaders on 13th July, which marked over 12 million coronavirus cases being recorded globally, World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus made a strong statement underscoring the importance of coherent public health messaging to an effective pandemic response strategy.1
According to the WHO chief: “mixed messages from leaders are undermining the most critical ingredient of any response: trust. If governments do not clearly communicate with their citizens and roll out a comprehensive strategy focused on suppressing transmission and saving lives; if populations do not follow the basic public health principles of physical distancing, hand washing, wearing masks, coughing etiquette and staying at home when sick; [then] it’s going to get worse and worse and worse.”2
In the same speech, the WHO chief defines three core strategies3 crucial to controlling the virus as lockdowns continue to ease:
1. Focus on reducing mortality and suppressing transmission
2. An empowered, engaged community that takes individual behavior measures in the interest of each other
3. Strong government leadership and coordination of comprehensive strategies that are communicated clearly and consistently
These three core strategies overlap and build on each other. Strengthening public health capacities and networks to “test, trace, treat” must be complemented by comprehensive precautionary strategies, drawing not only from effective public health communication, but also drawing from a scientific understanding of behavioral change interventions. How are risk information and health guidelines communicated, received, and processed by individuals so that these result in changes towards desired, specified behavior patterns?
Designing and implementing an effective communication response is complex, given that narratives and messages adapt, change, and evolve as they are applied to the local context. For example, in a meta-analysis of frameworks of behavior change interventions, one study shows that public health messages must be complemented by an understanding of capability and opportunity for an individual to deliver such calls to action. Behavioral change takes place not only in the context of wanting to comply to guidelines (motivation), but also given the physical and psychological ability to do it (capability) and the external factors that prompt it (opportunity).4
Behavioral economics provides an entry point to navigate around this complex terrain. By leveraging key concepts in the field, behavioral economic analysis offers practical insights in designing and implementing communication responses to shift public behavior, improve compliance, and achieve better outcomes.
Quarantine fatigue and diminishing sensitivity to risk
We focus on the Philippine case to contextualize our analysis of communication response strategies from the lens of behavioral economics.
The Philippine government imposed one of the strictest and longest lockdowns in the world, which started in mid-March. Despite this, as of the 17th of July, the number of coronavirus cases in the country is still growing at 61,266.
Since March, the lockdown has been deployed in phased approaches which have been categorized based on the degree of restrictions: from the enhanced community quarantine (very strict), enhanced community quarantine (strict), general community quarantine (less strict) and modified general community quarantine (relaxed). Each phase has a specific set of guidelines depending on priorities and assessment of the government’s COVID-19 Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF).5
One key effect of prolonged restrictions has been behavioral or quarantine fatigue, a human response directly correlated to the length and degree of the lockdown. Quarantine fatigue refers to the collective restlessness experienced by populations after a prolonged period of restricted movement. Staying at home has been an isolating, emotionally taxing, and financially challenging experience for many.7 After two months of restrictions, the Philippine government is pressured to relax its quarantine guidelines, not only for economic reasons, but also to ease public frustration and quarantine fatigue.
However, post-lockdown, the government will have to deal not only with a more restless and agile public, but also a public whose risk perception is relatively desensitized. This will put a strain on government efforts to bend the pandemic curve.
Source: https://ourworldindata.org/covid-mobility-trends using data published from Google LLC "Google COVID-19 Community Mobility Reports".
At this point, reverting to a stricter lockdown phase makes the policy prone to loss aversion. In behavioral economics, the concept of loss aversion refers to people’s preference to avoid losing something that has already been gained, which is estimated to be two times heavier or twice as painful compared to the pleasure from gaining the same thing.
While justifiable, returning to a more restricted phase is significantly more painful for the public (i.e. moving back to general community quarantine from modified general community quarantine) compared to gains from easing restrictions (i.e. moving from general community quarantine to modified general community quarantine). Thus, any local government that reverts to a more restricted phase is likely to face public backlash, which is already happening in several cities or provinces in various parts of the country. This could lead to further erosion in public trust and credibility of national and local agencies.
The key takeaway is this: the government needs to be able to make progress in bending the curve, because the cost of downgrading is far heavier and more painful than the gains from easing restrictions, which could lead to a stronger and deeper emotional dissatisfaction than what is already being experienced by majority of Filipinos.
Infusing behavioral perspectives to promote social distancing, wearing of masks, and staying at home when sick
Behavioral economics offers an evidence-based approach to assess specific challenges and design corresponding interventions from a human-centric lens. In this time of uncertainty, understanding how people behave and adapt must be at the core of an effective pandemic response strategy.
Post-lockdown, there are some core public health principles that need to be addressed in the ‘new normal’: physical distancing, hand washing, wearing masks, coughing etiquette, and staying at home when sick. With these objectives in mind, we outline key communication strategies drawing from empirical research in the field of behavioral economics.
1. Let the experts communicate the message
Receptivity to a message is strongly correlated with the person’s perception about the source of that information. Compliance to an action or guideline is shaped by the perceived authority and credibility of the messenger.6
Allow prominent doctors, public health experts, scientists and epidemiologists to communicate why it is important to wear masks, comply with social distancing, or stay at home when sick. Who conveys the message in posters, online promotional materials, commercial advertisements, or press conferences? Within public or private organizations, it is crucial to have an expert figure to convey announcements and messages about health guidelines. Any person is capable of communicating an information like wearing a mask or social distancing, but the weight associated with information coming from experts is stronger.
Another behavioral signal that can be leveraged is the relatability of the messenger. People are generally more sensitive to messengers who share a similar demographic background as the target group. In engaging with the youth, for example, the government can tap into social media influencers. In engaging with urban poor neighborhoods, barangay leaders or popular characters in television or media can be tapped to communicate the message.
Many observers and experts agree that the Vietnamese government implemented an effective communication response crucial to its success. Vietnam is one of the biggest countries to have eliminated coronavirus cases, recording no community transmission since April 15.
In an article released by a group of experts at the Exemplars in Global Health, Pollack and team posit that one of the main lessons from Vietnam is a clear, consistent, and serious narrative delivered throughout the crisis.7 They describe Vietnam’s strategy in the following manner:
“In late February, the National Institute of Occupational Safety and Health released “Ghen Co Vy,” meaning “Jealous Coronavirus,” a well-known pop song given new lyrics and turned into a handwashing public service announcement. The institute asked Khac Hung to rewrite the lyrics and dancer Quang Dang to choreograph dance moves, which ultimately spearheaded a dance challenge on Tik Tok. In March, the Ministry of Health sent ten SMS messages to all cell phone users in the country. Throughout these communications, the government constantly used the motto: “Fighting the epidemic is like fighting against the enemy.” This messaging engendered a community spirit in which every citizen felt inspired to do their part, whether that was wearing a mask in public or enduring weeks of quarantine.” 8
2. Enforce messages around social norm and commitment
Social norms have a strong effect on human behavior as they define what is socially acceptable. People derive signals from those around them to inform behavior, which has strong automatic effect on behavior.
In the context of COVID-19, the public may sometimes underestimate the percentage of the population that are complying with health guidelines. An intensive social norm campaign can be leveraged to induce desirable behavioral changes. One example of social norm messaging is by showing the various ways the public has been complying with health guidelines, and to leverage this to induce default behavior to follow.
The United Kingdom’s Behavioral Insights Team (BIT) has been at the forefront of the communication response, providing scientific and evidence-based insights to the Office of the Prime Minister and key government agencies such as the UK’s Department of Health and Social Care and the National Health Services. They have also been working with various governments and public bodies globally in disseminating and applying their findings.
Upon validating through a survey that people were keen to receive coronavirus communications advice directly through their phones, the UK’s BIT created a Covid-19 text service for the National Health Service. This initiative involved developing “customized text messages informed by behavioral science with advice on what they [the public] and members of their household need to do to stay safe.” 9 Those who did not want to receive messages could opt out.
The information conveyed via text messaging was based on behavioral research. The team communicated the rationale for isolation or quarantine measures in order to ease emotional and quarantine fatigue. They also leveraged social norm and commitment to encourage people to stay at home. Take a look at the set of photos below.
One key behavioral technique deployed was to highlight social norm and commitment: “If you live alone, text a friend or a family member to let them know you are following advice to stay at home until it is safer to mix with others. Plan to chat to someone over the phone at least once a day.” 10 This created not only an outward signal that those around would be doing it, but also an internal signal where other people’s expectation of you complying would be greater.
Another behavioral concept the UK BIT’s team introduced was planning and chunking time, drawing from previous behavioral research showing that this approach could ease individual anxiety. Take a look at the text messages below. How would you feel if you received similar daily text messages during the lockdown?
“Try to stick as closely as you can to your typical daily routine.”
“Are there things you enjoy doing at home that you usually don’t have time for?”
“Congratulate yourself and others in your home for reaching the halfway point.”11
3. Make it simple and easy
The EAST Framework from the UK’s Behavioral Insights Team provides an approach to encourage behavior, highlighting the need to make it easy, attractive, social and timely12. Simplifying the message could lead to better uptake of the message and significant increase in behavioral change.
One key strength of the behavioral economic methodology is its emphasis on evidence-based experimentation, making use of data analysis and iterating the process. For example, in improving its communication strategies, the UK’s BIT has meta-analyzed the effectiveness of its posters and digital materials through surveys. This allowed the team to understand response rates and how these were influenced across age and income groups and other demographic parameters. Take a look at how they revised their infographic materials in the photos below.
In their assessment, the UK's BIT put emphasis on keeping it simple: reducing cognitive load, putting the action at the top, giving precise advice, and shortening it. They also leveraged behavioral insights in incorporating the following principles:
a. use images and graphics, encourage social commitment
b. emphasize altruism
c. provide rationale
d. help people plan and chunk their time
The feedback loop mechanism allowed the UK’s BIT to understand the efficacy of the behavioral strategies based on various parameters, and improve it. Such analysis can incorporate variability in demographic responses (age, sex, income group) and robustness by understanding perceptions on how their messaging and design parameters led to desired behaviors.
Science-based responses to a complex problem
Behavioral levers cut across the emergency response spectrum. The coronavirus crisis had led to new contexts and experiences, which have implications on human behavior and the choice environment. Changes in the external environment, deliberate or not, induce specific human behaviors, responses, and adaptation strategies. The entire process of shifting to a ‘new normal’ can be described as an on-going experiment, requiring new ways of doing things and drawing insights about human behavior.
As restrictions continue to ease in most places, governments across the world are now increasingly recognizing the need to shift attention to behavioral communication strategies. Governments have no choice but to make progress, because the cost of downgrading is far greater at this point. Post-lockdown, governments will have to ramp up effective and targeted communication strategies to achieve desirable behavioral changes.
Think about the communication response of your government, be it at the national-, city-, or community-level. Consider too the communications and announcements you received from your companies or employers. Reflect on the following questions: Did you feel a human connection to the communications and announcements during the lockdown? Did they lead to desirable behavioral changes on you and those around you? Did they make you feel at ease and reassured, or did they generate negative emotions like anxiety, stress, confusion and anger?
2, 3 Ghebreyesus, T. A., 13 July 2020. WHO Director-General's opening remarks at the media briefing on COVID-19 - 13 July 2020. World Health Organization. Available at <https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---13-july-2020> Accessed: 17 July 2020. 4 Michie, S., van Stralen, M.M. & West, R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Sci 6, 42 (2011). https://doi.org/10.1186/1748-5908-6-42. 5 Omnibus Guidelines on the Implementation of Community Quarantine in the Philippines. 3 June 2020. Available at <https://www.officialgazette.gov.ph/downloads/2020/06jun/20200603-omnibus-guidelines-on-the-implementation-of-community-quarantine-in-the-philippines.pdf> Accessed: 17 July 2020. 6 Dolan, P., Hallsworth, M., Halpern, D., King, D., Vlaev, I., 2010. Mindspace: Influencing Behaviour through Public Policy. The Institute for Government and Cabinet Office, London. 7, 8 Pollack, T. et al. June 30 2020. Emerging COVID-19 success story: Vietnam’s commitment to containment. Exemplars in Global Health platform. Available at <https://ourworldindata.org/covid-exemplar-vietnam> Accessed: 17 July 2020. 9, 10, 11 The Behavioral Insights Team. April 8 2020. Using behavioural insights to create a Covid-19 text service for the NHS. Available at <https://www.bi.team/blogs/using-behavioural-insights-to-create-a-covid-19-text-service-for-the-nhs/> Accessed: 17 July 2020. 12 Service, O., et al. April 8 2020. EAST: Four simple ways to apply behavioural insights. Available at <https://www.behaviouralinsights.co.uk/wp-content/uploads/2015/07/BIT-Publication-EAST_FA_WEB.pdf> The Behavioral Insights Team. Accessed: 17 July 2020.
* Article cover photo by Liam Burnett-Blue on Unsplash