For taking on Covid, prioritize healthy behaviour, Health News, ET HealthWorld

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Students being briefed about social distancing guidelines before appearing in the examination of the 10th class at a centre, amid ongoing COVID-19 lockdown, in Kozhikode.Photo) (
Students being briefed about social distancing guidelines before appearing in the examination of the 10th class at a centre, amid ongoing COVID-19 lockdown, in Kozhikode.Photo) (

By Pooja Haldea & Pavan Mamidi

After close to two months of staying at home, there is a growing realisation that COVID-19 is here to stay and the lockdown cannot continue indefinitely because the economic cost is too high. As lockdown rules are phased out, the responsibility of practicing behaviours that stop the spread of the virus, such as social distancing or mask wearing, moves from the government to non-state institutions and individuals. How do we encourage people to practice protective behaviors, especially many of those which involve personal sacrifice?

Never before have we wanted to change behaviours in such a compressed time and at such a large scale. There are several challenges in the way of promoting healthy behaviour. Policing and monitoring the population is one route, but it is one that can only go so far in its reach. Foremost, opening up the economy may signal that risk has reduced and cause people to be more lax with protective behaviours. Motivating people to act otherwise with emotional messaging using fear or shame will eventually lead to mental fatigue. This is made worse by the devastating economic consequences of the lockdown, imposing tremendous cognitive loads on peoples’ minds. When someone is stressed about their financial situation, how will they have the bandwidth to think about protective behaviours? Furthermore, some of the recommended protections, such as social distancing in high density neighborhoods, are simply impractical in a country like ours. Could messages about social distancing among people who face unavoidable proximity lead to a reactive devaluation of messages that urge mask wearing?

Unlike mask wearing, which can be publicly monitored, hand-washing is often a private activity. How can we change people’s habits around these behaviours and do so quickly? It is well known that public health organisations have been trying to promote hand washing for decades, but we still lose 3,00,000 children to diarrhea every year in India due in part to its low uptake. Changing behaviour is hard and time consuming.

Establishing new social norms requires that they be enforced by others. In the least, as experimental evidence shows, third-party sanctioning is critical to the existence of social norms. But how do we prevent collective responsibility from turning into social vigilantism? How do we prevent it from hurting the most marginalised among us? And then, how can we maintain fairness in creating collective responsibility in a heterogeneous country for behaviours which are not equally accessible for different groups that are also unequally impacted?

Finally, how do we account for the impact on other critical health issues? The management and prevention of COVID-19 has overwhelmed our health systems and crowded our collective mind space. But in directing our focus to the pandemic, behaviours on other key health determinants have suffered. A prime example is that vaccination rates have fallen by 69% compared to this time last year. The result is that children who do not receive MMR vaccination are exposed to diseases such as measles, which are far more deadly for their age group than COVID-19. Another worrying statistic is the decrease in early diagnosis of TB – which kills 4, 00,000 people in India every year. Promoting social distancing and other behaviours is pertinent today – but it should not lead to people avoiding health services altogether. Much effort is needed within the health system to ensure the right balance of caution and care.

Given all these limitations, what can be done? First, we need to prioritise, and focus on areas where the issue is the most critical. In India, 15 districts are contributing 64% of the cases. Out of these, Delhi, Pune, Mumbai, Ahmedabad and Chennai account for nearly 50% of the total cases, So let’s narrow our problem to these urban hotspots. And devise solutions which work here.

Second step is to declutter: three behaviours are already too many. We need to prioritise the most critical behaviours, and these need to be feasible (i.e. people can do it), and sustainable (i.e. people can do it for the next 24 months). Not touching one’s face does not fall under this list, whereas mask-wearing does. Evidence shows social distancing and mask-wearing are the two most critical behaviours to prevent COVID-19. Where social distancing is not possible, we should ONLY talk about mask wearing. Where social distancing is possible, we should talk about both.

Thirdly, we need to make these behaviors easy. A good example of this is the government’s clear directive that any piece of cloth can be used to function as a mask, making it easier for people to comply both practically and cognitively.

Fourthly, we need to make an effort to turn these behaviors into social norms. Social norms are overt or unspoken rules that govern which behaviours are viewed as appropriate in society. Norms are frequently enforced by other members of the group and violating a norm can result in anything from social disapproval or informal sanctions to ostracisation. One way to do this is to embed social norms within communication campaigns, and then amplify them through all possible channels. The communication needs to incorporate 4 things, which we label as the 4-R model: Responsibility, Reminders, Reprimand, Respect. To begin with, the messaging needs to transfer responsibility from the government to each individual – each person needs to become not merely a complier but also an enforcer. Then, we need to ensure that there are many reminders of the norm. Norm non-compliance is often a by product of forgetfulness. Finally, we need a way for people to reprimand non-compliers, but respectfully. One way it can be done is by providing a script to people on how to ‘respectfully’ remind and reprimand non-compliers. A good example is how airline crews remind us to wear our seat belts, or to remain seated when the aircraft is in motion. The presence of a state diktat or a fine for non-compliers will also make it easier to respectfully remind people of the law as a part of the norm.

Another route to explore is role modelling by influencers. Our work has shown that use of celebrities who are likeable and relevant can go a long way in persuasion. Similarly powerful is the role of local influencers e.g., faith leaders. Role modeling by them will help give legitimacy to the new norms.

Lastly, we need to create visible safety features in our health facilities. It needs to send out a strong signal that the place is safe to visit. Think ‘safety features’ on the Uber home page – making focus on safety very salient. Further actions such as promoting tele-appointments, allowing only one patient in the doctor room, and de-marking and regular cleaning of high-risk surfaces are other things hospitals can do to increase safety.

In closing, it is important to clarify that what we are advocating is not a replacement of the state. It is not even a partial replacement of the state with self governance. Our position is not a call for anarchism, nor a libertarian, night-watchman state. On the contrary, our proposal is a very practical one to aid and strengthen the Indian government in promoting compliant and healthy behaviours. Although the task ahead is hard, focusing on one or two critical, feasible and sustainable messages, enlarging the threat of punishment from the state, coupled with using behavioural science to put in place new social norms could be our best solution.

(Pavan Mamidi is the Director and Pooja Haldea is the Senior Advisor at the Centre for Social and Behaviour Change, Ashoka University.) DISCLAIMER: The views expressed are solely of the author and ETHealthworld.com does not necessarily subscribe to it. ETHealthworld.com shall not be responsible for any damage caused to any person/organisation directly or indirectly.





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