Last Thursday, the World Health Organization put out a clear statement: ‘behavioural insights are valuable to inform the planning of appropriate pandemic response measures’. We agree, and it’s great to see that the WHO has put out a specific behavioural insights tool for COVID-19 and is recruiting for expert advisors in the field.
In part, this has been a long time coming, as the WHO’s website makes clear. The WHO’s long years of experience had taught it that the containment of epidemics, particularly when a vaccine or treatment is months or years away, is as much behavioural as medical. Ebola famously showed how important anthropology was to understanding how the disease was transmitted. Twinned with psychology, it also gave clues as to how one social habit, the urge to embrace, could be replaced with another (the ‘ebola’ elbow touch).
Similarly, the WHO has come to understand the critical role that can be played by effective communication, such as how to wash hands, and the importance of key messengers. The latter aren’t necessarily Presidents, or even medics. In the DRC, for example, it was the motards they had to convince (the trusted local taxi drivers).
The nature of COVID-19 means that the need for effective behavioural interventions is particularly pressing. With an effective vaccine thought to be at least 12 months away, effective containment rests on what epidemiologists call ‘non-pharmaceutical interventions’ – physical distancing, handwashing, mask wearing. In other words, changes in behaviour.
But how should these changes be achieved? Given the speed and complexity of the issues involved, there will always be debates and challenges about how evidence is applied. One of those discussions has concerned the idea that people might experience ‘behavioural fatigue’ under lockdown. As it happens, the concept did not come from BIT or our work, nor from that of SPI-B, the group of psychologists and social scientists who contribute advice to the UK’s Scientific Advisory Group on Emergencies. But it is still worth noting the emerging data on how behaviours in lockdown have changed over time; this is the first step towards the type of empirical evidence that can inform future policy judgments.
In the same spirit, BIT has been working fast to produce robust empirical evidence to inform decisions related to COVID-19. We have now run almost 40 trials involving 80,000 people, on key issues like handwashing, face masks, and physical distancing. After this many studies, we are now able to draw general conclusions on the patterns we are seeing. We can also scan the existing evidence to suggest new interventions that could be tested in the field.
While this is important progress in the fight against COVID-19, we don’t think the relevance stops there. Taking a step back, the period before we have an effective vaccine for COVID-19 may result in a stronger, lasting focus on the behavioural side of medicine. This is particularly true if such a vaccine is never found, which remains a possibility, or if effective treatments require patients to comply with difficult or unpleasant instructions.
At BIT, we’ve been thinking about these questions for a long time. Take our work in Moldova on tuberculosis. How can a disease that has had an effective treatment since the late 1940s still kill more than a million people a year? One major reason is that people give up with the treatment. They feel better. It has some unpleasant, though relatively mild, side effects. So they stop taking the pills and the illness comes back (and potentially more resistant).
To address this issue, the widely recommended practice is ‘directly observed’ treatment – in other words, don’t just give the patient the pills, but watch to make sure they take them! While that is effective–and has undoubtedly saved lives– it is a significant burden on both clinician and patient, with compliance generally achieved in less than a quarter of cases. A new study by BIT, UNDP and AFI – just out in the European Respiratory Journal – found that by switching to using a device to self-record taking the pills, compliance could be brought up to the WHO recommended 80% threshold.
The WHO’s move towards behavioural insights can therefore be seen as part of this behavioural shift in medicine. Behavioural science is definitely part of the strategy for tackling COVID-19, from strategic placement of handwashing stations to prompt people to wash their hands more often; to clearer communications; to providing support for people who are asked to self-isolate by a contact tracer.
The horror and economic dislocation of COVID-19 may also be reinforcing the fact that our greatest strength is our ability to cooperate at unprecedented scale – it’s called ‘public’ health for a reason. Behavioural science can help us understand how that cooperation can be sparked and sustained.