Introduction by Croakey: Just as COVID-19 restrictions were being eased across Australia, an increase in COVID-19 cases in Victoria has seen that state reimpose some restrictions.
It’s a sign of the uncertain road ahead. As reported in The Guardian, “what we can say for certain is that we will be inconvenienced in a number of ways for an indeterminate amount of time in many parts of our life”.
So how do we maintain long-term adherence to public health interventions in a community that is longing for a return to normalcy?
Public health advocates Ms Sian Ashton and Dr Lea Merone write that understanding the complexities of human behaviour change will be key in enabling continued community engagement with public health recommendations.
Sian Ashton and Lea Merone write:
As COVID-19 restrictions begin to ease, the future is uncertain; we don’t know if there will be a second wave in Australia, or indeed if the first wave has run its course. If cases do rise, will we be able to maintain public support for public health interventions such as working from home and physical distancing?
Recent projections from Harvard suggest that recurrent winter-time outbreaks will probably occur after the initial pandemic wave and to avoid exceeding hospital capacities, prolonged or intermittent physical distancing may be necessary into 2022.
If correct, this is a sobering thought. Policymakers will need insight into the factors that drive public conduct and develop strategies to alter this behaviour to ensure people adhere to appropriate restrictions.
Between late March and early May, Australians have experienced closures of various businesses including restaurants, bars, and social and sporting clubs. Schools closed and people were – and still are – advised to work from home if able.
After a long period of reduced human contact, including connecting with family and friends, it’s safe to say this is a nation of people who are keen to get back to some sort of normalcy.
Aiming for control
The Kirby Institute’s Professor Raina MacIntyre, Australia’s leading expert on biosecurity and infectious diseases, says that for the time being, we will need to aim for “control” of COVID-19, keeping the disease at a manageable level. This will involve differentiation between sustained community transmission and sporadic, non-sustained outbreaks.
MacIntyre concludes that to control the virus we will need widespread testing, vigorous contact tracing, ongoing travel bans, potential adoption of face mask use in the community, and continued physical distancing.
What can social and behavioural science tell us? The Behavioural Insights Team, a co-initiative of the UK Cabinet Office, explain that some of the attributes of emerging pandemics lead people to biased decision-making, which can impact their willingness to comply with prevention measures.
Complex behaviour change
The outcomes of preventative measures are as yet uncertain, but any potential benefits won’t be truly observed until some point in the future. Behavioural economists tell us this is a problem; any benefit in the future is generally valued less than benefits attained now, in the present.
To counter these values, they suggest that maintenance of public trust, clear, simple, precise messaging and transparency are key principles for how governments should communicate about COVID-19.
When making policy, there are six common errors when attempting to change public behaviour: that the solution is just common sense; it’s just about getting the message across; knowledge and information drive behaviour; people act rationally; people act irrationally; and it is possible to predict behaviour accurately.
Public health policy makers must acknowledge the complexity involved in behaviour change and develop an understanding of preceding behaviours in the form of patterns, practices and over-arching motivation.
Insights from the social and behavioural sciences relevant to pandemics tell us that threat perception (contagious negative emotions, optimism bias), the social context (social norms, culture, inequality), individual and collective interests (moral decision-making, group cooperation, zero-sum thinking), stress and coping (social isolation and connection, intimate relationships healthy mindsets), leadership (trust and compliance, shared social identity) and science communication (persuasion, misinformation, conspiracy theories) are key to understanding human behaviours in crisis situations.
Harnessing the insights from research on these topics helps to shape effective public policy.
Behavioural insights to improve and sustain health behaviour can be applied to policy through the Easy, Attractive, Social and Timely (EAST) framework.
The framework advocates for making public policy easy by using defaults, reducing the hassle factor and simplifying messages. Attract attention to the desired behaviour and design incentives for maximum effect. Making it social by showing that most people perform the desired behaviour, encouraging people to make a commitment to others and using the power of networks. Making it timely by prompting people when they are likely to be receptive, considering immediate costs and benefits and helping people plan their response to events.
Nudging the public
Behavioural economists have built on the policy tools of regulation, information and incentives to influence behaviour through nudges.
Nudges refer to subtle alterations to people’s choice environments while still enabling people to make their own choices. Nudges are an effective solution to altering some population-level behaviours to improve public health.
Nudges have been used in public health to reduce smoking – reducing cues for smoking by keeping cigarettes and smoking equipment out of sight in shops; influencing healthy food choices through food placement in supermarkets; reducing alcohol consumption by serving drinks in smaller glasses; and increasing physical activity by making cycling a more attractive option by creating safe and clearly signed bike paths.
Examples of nudges we are now seeing in the era of COVID-19 are hand sanitising stations in public buildings and restaurants, and crosses marked ‘1.5m apart’ on the floor in supermarkets to remind people to maintain a physical distance.
Nothing about us without us
The Australian Human Biosecurity Emergency Declaration for Remote Communities, issued in March, has affected entry into remote communities with significant Aboriginal and Torres Strait Islander populations. Remote Aboriginal and Torres Strait Islander communities are at an increased risk of COVID-19 due to high rates of other health issues, issues with access to health care, reliance on outreach services, community mobility and overcrowding of housing.
While these measures were put in place in collaboration with First Nations’ peoples, there was understandable community anxiety about the restrictions due to the history of paternalism in Australian Indigenous policy-making and a perceived inequality in restrictions for Aboriginal and Torres Strait Islander peoples and non-Indigenous people.
It is vital that there is respectful engagement with Aboriginal and Torres Strait Islander communities to develop effective policy on pandemic mitigation, both in remote areas and in urban areas. Community control of culturally appropriate pandemic containment strategies has been identified as key to community uptake of public health recommendations.
A way forward
Public health policymakers should work closely with social and behavioural scientists and behavioural economists to harness insights into human behaviour to create the conditions to enable continued public engagement with public health recommendations.
There should be an awareness of the assumptions, or errors, that can be made when formulating public policy and evidence-based models like the EAST framework can be used to guide policy development.
First Nations people must continue to have self-determination when it comes to decision making about public health responses for themselves and their communities.
Sian Ashton is a senior public health officer with 20 years experience working in public health in a number of global settings, including the Ebola response in Sierra Leone, for which she was awarded the Humanitarian Overseas Service Medal.
Dr Lea Merone is a public health physician and PhD scholar.