The novel coronavirus pandemic has gripped much of the world due to the strain it places on healthcare systems. Similarly, combatting the pandemic has placed a strain on regular human behavior. Successful pandemic response requires a massive societal-level behavior change to buy societies the time required for scientists to develop and test better treatments, vaccines, and technical tools to “flatten the curve” of new infections.
Rapid widespread testing for the disease and technological tools for contact tracing are critical components of a coherent response to Covid-19. But the first and arguably most critical line of defense runs through changing basic human behavior concerning interactions with each other in social and public settings. If this unprecedented exercise in behavioral change is to succeed, understanding the most effective strategies for communicating best practices for citizens to follow is essential.
The behavioral changes required to fight the pandemic are instructive because of how deceptively simple they appear at first blush. Citizens are not being asked to change their dietary habits or to exercise more vigorously or more regularly, let alone to give up addictive behaviors such as smoking or alcohol abuse. Instead, the message is simple: avoid all unnecessary social contact with non-family members, maintain physical distance when contact is unavoidable, wash hands with soap and water for at least 20 seconds, and wear a mask that covers one’s nose and mouth in all public spaces, and especially indoors.
Not that complicated, yet as the science of behavior change makes clear, such key behavioral changes are deceptively hard to implement because of how fundamentally they alter human interactions.
Educating citizens
How effectively governments communicate the behavioral changes required to fight Covid-19 will determine when and how societies can return to a semblance of normalcy.
Government-mandated lockdowns are not sustainable indefinitely. Yet, as the disastrous response of the United States makes clear, easing restrictions on public interactions is inevitably linked to a spike in infections unless citizens assiduously adopt best behavioral practices. Understanding why some citizens do so, while others ignore the advice of public health professionals, requires grappling with macropolitical dimensions such as trust in government and the legitimacy of technocratic expertise in different societies. But that’s beyond the scope of our inquiry.
We focus instead on a more elemental feature of government responses to Covid-19 – namely the design of the ubiquitous images plastered on billboards, signs, and posters across our towns and cities, not to mention via social media, that use infographics and images to educate citizens about what they should do to #flattenthecurve.
These images are an easily accessible data source that illuminates how well government communications adhere to accepted best practices for health communication.
In India, MyGov has been the primary creator of the posters we examined. MyGov rolled out a series of campaigns such as the “New Normal” campaign in June, outlining dos and don’ts of the coronavirus pandemic. Another main actor at the Central level is the Ministry for Health and Family Welfare, which is tasked with Indian health policy.
Both arms of the state focus on behavior change in their public campaigns to fight the pandemic. State communications, which typically follow the templates established by the Central government agencies, either come from state governments or from the state branch of MyGov. The state campaigns mainly translate the posters as needed into local languages.
Health communication is a science, not an art
Behavioral change communication best practices aim to maximise the reach of a message and the uptake from its target audience. In the case of Covid-19, governments must achieve two related but distinct goals: to teach citizens the risk of the disease and to inform them about the behavioral changes required to minimise the spread of the virus.
Vast research into the science of health communications identifies the following desired elements for such campaigns – that they should be specific, culturally and contextually appropriate. Communications, specifically mass information campaigns, should account for what we know about the cognitive biases caused by different emotions affecting how we filter and classify information. For instance, overly negative “scare-tactic” communications can create a paralysing effect that leads to avoiding any real change, a real danger with Covid-19 since societal anxiety and stress levels are extremely heightened due to the unprecedented dislocations caused.
In contrast, more positive communications focused on what individuals can and should do serve as a motivator to act and change behavior. Evidence from the behavioral science field also shows strong social persuasion and peer pressure effects – perceiving that other people are adopting a certain hygiene behavior increases the likelihood of you doing it too. And in coronavirus times, “quarantine-shaming” – the practice of judging your friends and neighbors into staying at home, washing their hands, and wearing masks – has become even more common.
So communications should tap into this wealth of cultural and social potential, emphasising for instance both that the practices being promoted are widespread (“people just like you are already doing this; you should too”) and that it is an ethical duty to others to do so (“wearing masks saves lives”).
The science behind behavioral communication might be clear, but the art is in converting these principles into mass communication campaigns. How well has this been done in India? A minimal standard by which to assess the government’s efforts is to evaluate how accurately the posters they promote represent the science that is currently known on the virus, specifically the need to wear masks that cover the nose and the mouth, to maintain at least six feet or two meters physical distance between people, and to wash one’s hands with soap for at least twenty seconds.
But as anyone who has ever been a student knows, it’s one thing for teachers to know the material, it’s another thing as to whether they can communicate it effectively. Therefore, we also suggest two additional dimensions by which the government’s behavioral change campaign might be usefully evaluated: accessibility (the cultural appropriateness of the graphic and how “natural” it seems) and comprehensibility (is the image a wall of text that citizens will ignore?). Images and posters that rely heavily on jargon or impossible-to-frame risk analysis set themselves up for failure.
Assessing India’s behavior change campaigns
India has vast experience with public behavior change campaigns that have been deployed to promote family planning (hum do, humare do) to the national Swacchh Bharat campaign against open defecation. But, to our knowledge, the efficacy of these mass media behavior change campaigns has not been evaluated rigorously by social scientists. With Covid-19, the rapid timeframe in which the government had to respond made testing behavior change strategies through experiments or field-based randomised control trials, the gold standard in testing whether communications work, an understandable impossibility.
So instead we propose a more reasonable post hoc standard by which to evaluate the communications used: did they get the information correct and was the communication accessible and comprehensible?
In a nutshell, our survey of Covid-19 posters reveal that while most are very creative, they vary in terms of their accessibility and comprehensibility, and, perhaps most troublingly, in the accuracy of information depicted.
There are a few “poster children” that hit their marks: they are clear, concise, simple, and engaging. The MyGov bulletin pictured below ticks off the boxes for transmission accuracy, social norms, and comprehensibility. It is part of the New Normal campaign launched in June, so MyGov had some time to iron out kinks in their formula.
All figures are wearing masks that cover their noses and mouths; there is a clear list of “dos” that are relatively feasible; and the colors are cheerful, hopeful, and eye-catching. (The poster does however suggest a “one meter” rule of thumb for physical distance which is at odds with other advice given by MyGov that stresses double that distance. This difference reflects changing international guidelines, so our point is not to criticise the designers but to highlight how apparently contradictory information from the same source might confuse the target audience.)
The phrase “new normal” in their campaign evokes social and collective responsibility. And in regards to comprehensibility, it is relatively easy-to-read, foregoing a wall of text and recommendations for six easily digestible graphics that each show an important step for flattening the curve.
Similarly, the Nagaland state bulletin below is comprehensive in terms of transmission accuracy: it covers the three pillars of washing hands, social distancing, and mask wearing. It even goes further than MyGov in providing specific action numbers to call and a demonstration on hand-washing with soap.
However, what it provides in content it sacrifices in comprehensibility. It still has plenty of engaging graphics; however, the information is not well organised and contains a wall of text that strains cognitive capacity and challenges attention spans.
Social norm based advertising has been innovative, taking advantage of India’s culture of social responsibility and family welfare. Of particular note is the “Be like Amaaji” campaign. Amaaji invokes the norm of a specific, identifiable family elder rather than another, amorphous person, taking advantage of India’s multi-generational household culture. The #IndiaFightsCorona featured hashtag encourages a social, collective approach in the use of the hashtag to connect to social media, and connects individual communications with the idea that everyone is fighting together.
Similarly, other communications focus on care, with a MyGov communication indicating broad societal consequences for “carelessness.” A poster advertising curfew for Jharkhand indicates curfew is “Care 4 U”. Another myGov communication emphasises social distancing for one’s family – all emphasising the idea of mutual care and responsibility.
More troublingly, there are also examples of (perhaps unintentional) deviations from best practices. The poster below is focused on discouraging mass gatherings, but in doing so it fails to reinforce the critical messaging about maintaining physical distance between individuals or the importance of wearing masks. Should we read the injunction that authorities “take necessary precautionary measures” if mass gatherings do occur as encompassing the distribution of masks? This omission runs counter to the goal of cohesive and comprehensive messaging.
More problematic posters are those that substitute established medical and public health advice with folk wisdom. For instance, while no one would disagree that good hydration is desirable, the suggestion that drinking “fresh juices” will boost immunity to Covid-19 is not based in medical knowledge.
Likewise, whether exercise and meditation helps elderly people avoid Covid-19 is unclear at best. Our point is not that such advice is inherently problematic but that it distracts from a clear and consistent messaging on how to minimise risks during the pandemic.
A more worrisome example of such advice-giving is a MyGov communication from April (below) encouraging citizens to take hydroxychloroquine as a prophylaxis. Not only is there no evidence that doing so has any positive effects, but there have been cases suggesting that taking this medication can have very dangerous side effects for patients.
To be fair, the MyGov communication does say “as prescribed” but the suggestion that this course of action had government sanction could have led worried citizens to pressure their doctors for prescriptions and to believe themselves to be have a greater immunity to Covid-19 for having taken a drug with no proven prophylactic power.
Such folk analogies (drink juices) and inconsistent messaging (1 meter distance versus 2 meters) take the focus away from best practices, like hand-washing and mask-wearing, which should be the basis of a coordinated behavioral change communications strategy that relies on strong message discipline based in clarity, simplicity, and consistency that together make messages easier to comprehend.
By adding their own wrinkles, such ad hoc advice, in official government communications actually dilute the impact of their own messages.
Message discipline
Covid-19 is the most significant public health challenge the world has faced in our lifetimes. We are learning in real time the full extent of the damage it wreaks on some of its victims, how the disease spreads through asymptomatic carriers of the virus, the disproportionate impact it has on some communities and age groups, and the combinations of treatments that are most effective in hospital settings.
The most effective countermeasures to stem the spread of the virus have involved harsh society-wide lockdowns that have caused incredible economic pain, not to mention mental and emotional health costs that will only be fully accounted for in the years to come.
Even as we all wait breathlessly for news that a safe and effective vaccine has been found, the simple logistics of producing any vaccine candidate on the scale required for global use means facing up to the fact that we will all be living with Covid-19 for some time to come. Until herd immunity is achieved globally, the only way to protect citizens from the disease, and to minimise the burden it places on public health systems, is to promote widespread behavioral change.
To enable that, governments the world over, as in India, have engaged in mass media communications to teach their citizens how to act in the “new normal”. But, as our analysis illuminates, the content of these government messages varies in unhelpful ways, and many official communications do not adhere to well-understood tenets of behavior change communication.
The good news, though, is that following the simple rules of message discipline, accessibility, and communication would generate more consistent and coordinated campaigns with greater chances of success. MyGov India and other state agencies should ensure that all government communications follow these principles; doing so will literally save lives.
Tara Soni Bhagat was an intern at the South Asia Center at the Atlantic Council in Washington, D.C. and an undergraduate psychology student at the University of Cambridge.
Irfan Nooruddin (@irfannooruddin) is Director of the South Asia Center at the Atlantic Council in Washington, D.C., and Professor in the Walsh School of Foreign Service at Georgetown University.