Behavioural Nudges for better health and hygiene practices in rural Bangladesh (Part 3)

SOCIAL DISTANCING, SOCIALLY UNACCEPTABLE

In this final part of our blog series, Behavioural Nudges for better health and hygienic practices in rural Bangladesh, we discuss and celebrate one of our failed prototypes

During the design phase, one of the best local examples of nudges was the painting of circles in front of shops to designate standing spots that ensure social distancing. However, in December 2020, our field staff reported that in most cases the paint had faded away and the nudge was utterly ignored.

Moreover, they reported that shop fronts were a prime spot for the transmission of covid-19 due to the congestion of customers during peak hour. Based on this information, we designed an intervention that communicated on social distancing, was placed directly in front of the counter and would be hard to miss, and provided clear guidance on where to stand.

We approached 13 pharmacies with this intervention, but the prototype was implemented at 7 pharmacies, with the remaining 6 pharmacies refusing to implement this nudge due to scepticism on the feasibility of social distancing. This was tested for 21 days across two districts. Through a series of focus group discussions and interviews conducted on a field survey, our field implementers observed and collected data to assess:

- If the messaging implemented were still at place
- Whether social distancing was being maintained

By the end of the implementation period, only 2 of the 7 pharmacies still had the intervention in place. During the observation sessions, our field staff reported that most customers ignored the messaging as some of them continued to lean in over the ribbons. During rush hours, customers became agitated when asked to maintain distance. Consequently, this discouraged the pharmacists to continue pursuing this prototype — fearing loss and dissatisfaction of customers.

Our conversations with the pharmacists revealed that social distancing was maintained well during the first 6 months of the lockdown. This was mainly because of strict and proactive mandates by law enforcers. However, as the lockdown eased and lifted, the general public grew more reluctant to adhere to these rules.

In some pharmacies, black ribbons or Bamboos were already set up to try and create a barrier between the pharmacist and customers and prevent customers from leaning on the counter. According to the shop staff, these measures were useful towards the beginning, but are completely disregarded by customers now.

We hypothesise that this is because, for these densely populated areas, social distancing is simply not feasible. The local population mostly consists of lower income groups whose jobs and lifestyles require them to spend long working hours in crowded areas. The impracticality of practicing social distancing and the lack of enforcement (as done during the early months of lockdown) have left most low income and low literacy groups in denial about covid-19 and the need to socially distance. It is also considered to be culturally inappropriate and disrespectful to actively maintain distance from fellow community members.

In light of these findings, we recommend shifting away from trying to increase compliance with social distancing and instead emphasising the proper use of masks, as the preferred alternative, especially in crowded areas. At the pharmacy, this can be achieved through posters or stickers with messaging that focuses on reminding people to wear masks especially in crowded areas. The same messaging should also be put up in areas where it is difficult to socially distance oneself (e.g. public transport, market places, etc.).

At the national level, the same messaging can be targeted to rural and low income communities through IVR recordings from telecom providers instead of messages that promote social distancing to an audience that is (a) fundamentally unable to comply and (b) have become desensitised to a prescription that is irrelevant to their lives. At the household/community level, this can also be supplemented by BCC campaigns like yard sessions at community levels and schools as an effort to further ingrain these health messages.

This brings us to the end of our 3 part series on rapid prototyping of behaviour change interventions for covid-19. If you’re interested in the application of design thinking, rapid prototyping, and public health innovations, follow us on medium, twitter, and facebook! Feel free to get in touch — we love a good conversation or brainstorm.