What are people’s perceptions, behaviours, and information-needs in dealing with the ongoing pandemic in India? Between March 20 and June 10 , Noora Health, in partnership with YosAid Health Innovation Foundation, conducted phone interviews with more than 6,000 respondents in four states to understand this. These respondents were sampled from an existing database of people who had recently sought health services in public health facilities in these states: Karnataka, Madhya Pradesh, Maharashtra, and Punjab.
Like many other phone surveys conducted during this period, Noora’s phone survey finds that the humanitarian and economic impacts of the lockdown were widespread. In addition, this survey also documents unique evidence on the response to the Covid-19 pandemic itself. This evidence pertains to people’s knowledge, attitudes, behaviours, and risk perceptions. Unlike the effects of the lockdown, these aspects of response to the pandemic are less understood. This article discusses some of our main findings.
We found that the self-reported practice of behaviours that can help prevent the spread of disease has improved considerably. The graph above shows that a large proportion of respondents reported they are washing hands and wearing masks to avoid infections. The practice of wearing masks has increased substantially – from less than 40% in the middle of March, to about 70% in the middle of June. The wide penetration of these preventive behaviours in an under-resourced setting like India is a remarkable achievement. It shows the value of clear and consistent public health messaging.
Admittedly, because these behaviours are self-reported, there may be some over-reporting of their practice. Recognising this, we did not prompt any behaviours specifically, but just asked what people were “doing to prevent infection?” In any case, there is scope for improvement. A widespread understanding of the importance of these behaviours and their self-reported practice also provides a foundation for further nuanced messaging on the proper practice of these behaviours.
A smaller proportion of respondents reported that they were practicing physical distancing or avoiding crowds. In June, the proportion who reported they were avoiding crowds or maintaining distances was about 20%. The proportion maintaining distances has remained stable throughout. The proportion of respondents who said they were avoiding crowds had fallen by half, from about 40% in March to 20% in June. The lower practice of distancing measures is understandable, given economic necessities in India. Many people find it hard to avoid crowded places given the nature of their work and related travel arrangements.
To a smaller extent, knowledge about the likely mortality impact of the disease has also improved. Current scientific understanding is that the infection fatality rate is between 0.6%-1% in the general population. Fatality rates are higher for older people. By June, more than three in five respondents knew that most people would recover from the infection. A higher proportion knew that older individuals and those with existing diseases have a greater mortality risk.
This knowledge can be improved further. This will help more people understand that older people or those with weaker immune systems need to avoid crowds and practice social distancing much more stringently than healthier younger people.
Even as reported behaviours in response to the pandemic are encouraging, people’s perceptions of the risk of getting infected from Covid-19 are disconcerting. The graph below shows that a very small proportion of people – about 10% in June – believed that they or their family are at risk of contracting the disease. Even more worryingly, this proportion has been falling.
The risk-perception has been declining even as the number of cases detected each day have been increasing. Our qualitative interviews, which we conducted along with the survey, provide some insight into why the risk-perception is low and declining.
First, few people know someone who has been infected. Second, because they are taking precautionary measures, people believe that they are not likely to catch the disease. A respondent in Maharashtra told us, “No, we don’t have any risk, because no one is sick at our place and we are not stepping outside.” Falling risk-perceptions may make people less-likely to practice healthy behaviours. As economic activities resume, it is crucial to communicate a more balanced view of the risk of getting infected from Covid-19.
The graph above also shows that more than two in five respondents did not know about asymptomatic spread. This proportion has also remained constant. The lack of understanding that infected individuals can also be asymptomatic and have the potential to spread the infection is likely to impact the risk perception. Recognising that disease spread can occur unintentionally from contact with asymptomatic but infected individuals is very important. Correct understanding will allow people to be alert and practice preventive behaviours. This also has implications for ensuring successful contact tracing.
Beliefs about risk, spread, and mortality that are not rooted in evidence may jeopardise gains made by improvements in the practice of preventive behaviours such as the adoption of masks. They may also lead to a lowering of precautionary measures themselves. Our survey, which tracks beliefs about Covid-19 over time, suggests that beliefs can change, and that public health communication can be effective. It is worth improving public understanding.
However, a challenge in addressing these beliefs now is that a large amount of information – of varying quality – has already been communicated. There may be some fatigue with information about the disease. People may already be oversaturated or may feel that they already know about the disease. The survey finds some evidence that people believe they have enough information about the disease.
We asked respondents “what information would you like to hear more about the coronavirus?”. Respondents could pick multiple answers. By the end of May, about half of the respondents felt that they had enough information about the disease and did not need any information. The proportion of respondents saying they have enough information has increased rapidly, from less than 20% in late March to 50% of respondents in early June, illustrated in the below graph.
These responses likely reflect the infodemic that has accompanied the pandemic. A respondent in Karnataka told us, “I don’t want to know anything, the more I know the more it makes me feel anxious.” It is worth noting here that over 70% of respondents said that their primary source of information on the disease was television news channels. Although mediums such as the news help reach a large audience, they limit the ability of people to ask questions and voice their concerns.
Behaviour change communication involving training families admitted in public district hospitals through “Care Companion Program” is our core work. Since the onset of the pandemic this strength helped us fashion a Covid-19 response plan to help communities. We are also involved in programs to train healthcare workers, NGO frontline staff, and family caregivers of home quarantined Covid-19 positive patients. The survey helped us understand the needs of the community to develop and finetune our response plan and the education content accordingly. We have created and are actively sharing engaging, comprehensive content incorporating design-thinking principles and a human-centred approach developing 15 key modules in 12 languages in multiple formats.
Public health communication faces the challenge of presenting correct and balanced information, without being unnecessarily alarmist. These findings and our work highlight the nature of the challenge that public health communication faces now. It is worth emphasising here that public health communication while crucial, is but one component of an overall response to the pandemic. Other institutional and structural components, such as testing and tracing, the response of the healthcare sector, and social support for people to brace economic hardships are also important.
Yet, in a setting like India with historical structural deficits in healthcare, balanced and evidence-based public health communication is even more important. Not all the rapidly evolving scientific understanding of the disease needs to be communicated to every member of the public. Making sure that the public understands the evidence that is relevant to prevent spread and protect health at the individual, family, and community levels needs even more concerted efforts now, when lockdowns have eased and the average person thinks that they understand the disease.
Aashish Gupta is at the University of Pennsylvania. Seema Murthy, Arjun Rangarajan, and Shirley Yan are at Noora Health and their partner organisations.