6 behaviorally backed ways to respond to COVID-19
The containment of previous outbreaks shows the potential impact of approaches like building trust and fighting misinformation, especially in humanitarian settings.
At the height of the West African Ebola outbreak in 2014, the international community was working around the clock to build dozens of large field hospitals and supply them with medical equipment, as part of a mass treatment strategy. I had been deployed with the UN to Liberia to support these response efforts. However, we rapidly ran into unprecedented challenges. Despite an ever increasing caseload, and more than enough beds to treat the sick, the hospitals were mostly empty. At first these types of contradictions puzzled us.
It became clear that containing an outbreak requires more than a medical or infrastructural approach. It requires an understanding of the complexities and drivers of human behavior. Behavioral science, which includes theories and evidence from economics, psychology, anthropology, and cognitive science, might have helped us understand that many of the challenges we faced were more “human.” The spread of a virus is almost entirely dependent on its host behaving in the ways that make us human: our compassion and culture, such as the care-taking of a sick loved one.
But the spread is also fueled by other human behaviors: mistrust and misinformation. During the Ebola crisis, many believed that the virus wasn’t real, others shunned treatment centers fearing that anyone who went in would never come out. Later, it was found that up to 40% of deaths were occurring outside medical centers, indicating that people weren’t seeking treatment.
There are many valuable behavioral lessons from our responses to 21st century epidemics and pandemics in Asia and Africa. However, COVID-19 is also fundamentally different from any other disease outbreak we’ve experienced in recent history and new interventions will need to be introduced globally, including in vulnerable humanitarian contexts.
Work with communities to identify trusted messengers
Containing a pandemic is only possible if people strictly follow preventative behaviors like self-isolating. When people don’t trust the messenger, they may be less likely to follow such recommendations. In the Ebola outbreak, high levels of mistrust in government and health professionals were associated with lower odds of having taken preventative actions or treatment-seeking.
Governments are currently taking the lead in sharing information to populations about COVID-19, however, evidence shows that politicians are some of the least trusted sources of information worldwide. So who are the most trusted messengers? Globally, it tends to be scientists, doctors, and teachers. But context and audience matters.
In the Ebola outbreak in the DRC, some people rated their trust in healthcare-workers very highly, but many others feared medical teams due to rumors that they were intentionally killing civilians. Religious leaders were instead found to be the most trusted and successfully advocated communities to engage in new practices, such as safe-burials.
In responding to COVID-19, research and human centered-design approaches can help us establish who the most trusted messenger is for each context and population group, and ensure they are the ones communicating key messages to overcome the lack of trust we have seen undermine efforts in other pandemics.
Make response transparent
Often fears and rumors can be exacerbated by the perceived opaqueness of a response. In both the 2015 and 2018 Ebola responses, the physical design of treatment centers became more open, allowing space for family and friends to visit and see their loved ones recovering. Simply putting in an exit sign had a positive impact by indicating it was possible to survive and leave. Similarly, a shift to community-based treatment, with centers built together with communities and often staffed by trusted and familiar faces, provided a major turning point in the response.
It’s not just physical spaces that can benefit from transparency. Experimental studies have shown that operational transparency — showing progress or work behind the scenes — improves trust. Where possible, organizations should show people how they are responding and addressing feedback, perhaps through two-way communication channels and regular consultations with affected communities.
Stop disinformation before it spreads
Findings from recent outbreaks, like SARS, have documented strong correlations between the spread of rumors and the scale of infections across regions in China. In past responses, some efforts to counter misinformation have focused on tracking rumors and “myth busting.” However, there is mixed evidence as to whether these methods work. Some evidence suggests that direct-refutation and fact-checking is at best ineffective, and at worst, actually reinforces beliefs.
We’re already seeing a surge in rumors and conspiracy theories related to COVID-19. Behavioral evidence suggests that people are more likely to believe conspiracy theories during times of crisis as a way of filling in the gaps in our knowledge and regaining some sense of psychological agency over a situation that is both uncertain and important. Rather than trying to counter belief in misinformation retrospectively, organizations could instead try to preempt it. Based on the theory of “psychological inoculation,” studies have found that if people are exposed to common disinformation tactics used, they gain psychological resistance to, and are less likely to believe, false information they encounter in the future.
Similarly, other studies have found that prompting individuals to question information using certain rules of thumb that are easy to follow like, “Always check the source of the claim” can reduce the likelihood of people believing fake news once they’re later exposed to it.
Simplify, specify, and contextualize communication
Facing a pandemic is overwhelming for all of us, but in a humanitarian context, communities face additional structural challenges such as limited access to water, overcrowded living spaces, and the lack of opportunities to generate income from home. The scarcity people experience in these contexts, such as living in poverty, also creates psychological challenges. Evidence shows that lacking time or money directly impacts people’s cognitive function, leading them to make poorer decisions and reducing their ability to recall information.
Complex guidance should be simplified, prioritized and contextualized so that people can realistically use it. The UK National Health Service is testing behaviorally-informed messaging with vulnerable populations, simplifying more than 3,000 words of complex guidance into prioritized daily SMS messages and adapting messages based on the physical space constraints of populations. Social distancing, for example, is difficult for people if they share a house with 10 others or need to physically go into work to earn a living. Better communications would include specific actionable behaviors such as, “Always stay at least two arms lengths away from others when outside your home.”
Similarly, organizations should help people to easily follow through with desired behavior changes. This could, for example, involve changing the way relief-items are distributed to facilitate social distancing and enable easy handwashing.
Show people what the hidden social norm is
We are inherently social creatures who have evolved to take cues from others and therefore, we tend to conform to the behaviors and attitudes of those around us. However, when positive social norms are hidden, people may fail to change their behavior accordingly. Simply informing people what “most people do” has proven to be an effective behavior change strategy to encourage positive behaviors, from increasing tax payments to increasing rates of vaccination.
According to a recent survey of citizens from 58 countries, while the majority of people personally supported cancelling social gatherings in response to COVID-19, they vastly underestimated the extent to which their fellow citizens did (by 30 percentage points!). To increase the prevalence of these types of preventative behaviors, we can use visuals or messaging such as, “Most people in your community increasingly believe we should all be staying inside as much as possible to avoid risks of COVID-19.”
Increase public acceptance of, and compliance with, response measures
The introduction of more stringent policies, such as the restriction of movement, can rapidly shift what a community sees as “normal.” However, these measures may work best when they are accepted and supported by the public. During the Ebola outbreak, for example, coercion sometimes backfired, fueling mistrust, civil disobedience, and unrest.
Studies on responses to issues from climate change to the Swine Flu have found that public support of, and compliance with, a behavior change policy or intervention may increase when people believe it is having the desired effect. It will be important to communicate to citizens that policies like lockdowns are already working at reducing the spread of disease.
Behavioral science evidence also shows that when people are involved in and contribute to something, it tends to increase their sense of agency, ownership, and understanding of it. Engaging in consultative and deliberative forums will be critical to gain public support.
We will only be able to contain COVID-19 if we stop its spread everywhere, including for the world’s most vulnerable people living in humanitarian contexts. We can learn valuable lessons from Africa and Asia, which have used behavior change to contain other outbreaks with limited medical and financial resources. Whether it’s asking people to avoid seeing their loved ones for months or to forfeit elective medical procedures, people are being asked to do difficult things under increasingly challenging circumstances. Learning our behavioral lessons from previous outbreaks, we can design a more effective response for COVID-19 by including an understanding of real people and what drives them.
The six behavior change strategies above link to many of the other great behavioral resources which have been shared, from within our own team and many other academics and practitioners in this field. We hope this article invites others to share similar insights from these contexts.