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The social and behavioural sciences (SBS) in public health have had an essential but relatively unacknowledged role since the beginning of the field in the early 19th century. Over the last few decades, there has been a slow and gradual paradigm shift in the field globally with growing acknowledgement of the need for SBS research to drive interventions for successful public health outcomes.
However, in India, experts argue that public health continues to be dominated by a biomedical approach to health. In public health, infectious disease management is a high-priority area due to the large number of existing and emerging infectious diseases, such as malaria, measles, diarrhoeal diseases, tuberculosis, Ebola, Zika, Nipah, etc. All of these pose numerous and complex challenges in detecting and managing them. While SBS approaches in disease outbreak investigation and management have been used in the past, the systematic inclusion of social science-based interventions (SSIs) as an integral part of operational response remains a challenge.
In India, SSIs have also been used but only in a relatively episodic manner, relegated to targeted interventions focused towards dealing with conditions like HIV/AIDS and tuberculosis. However, SBS methods, to be effective, must be developed in an integrated manner with affected populations to bring a disease outbreak or health emergency to an end. In addition, there needs to be a systematic use of methods and analyses to understand the cultural and social contexts of communities affected by health emergencies, as well as the need to detect behaviours and practices that increase the risk of death, disease or social and economic loss.
In the current COVID-19 crisis, epidemiologists and other health experts are working tirelessly to understand the scale of the problem and to help develop strategies to mitigate risks associated with it. In addition, scientists in both the public sector and private enterprises are racing to develop tests and vaccines. However, social and behavioural scientists can also play an important role in the current pandemic, especially given the current absence of any vaccines and medicines.
SBS interventions such as effective communication (improving awareness of the virus and risks) and behaviour change (physical distancing, frequent hand washing, avoiding mass gatherings, etc.) are critical at this juncture to contain the transmission of the virus and flatten the curve. In addition, established social interventions, including social mobilisation, health promotion through education enable community level adaptations to comply with the new social norms. These measures give the government a critical window to strengthen the health system and evolve strategies for testing, isolation and contact tracing of new cases.
For effective communication, we need to understand the intended audience, level of public trust in the people conveying the message, and the level of public awareness of the pandemic. The aim of good messaging should increase public awareness, reduce the anxiety and distress that arises, and also facilitate the behaviour change that might be required by the people in such situations.
So how can we use SBS to inform effective communication over COVID-19? Successful communication campaigns have incorporated accuracy, consistency, clarity and empathy as key components. In contrast, ill-informed communication strategies carry the risk of precipitating behaviours that run counter to stated public health goals. This risk is exacerbated in a people whose cultural familiarity and risk perception is low in behaviours such as physical distancing, making adherence to them difficult. Studies report that ambiguous and inconsistent messaging increases chaos, confusion and distrust, leading to non-compliance to the behaviour change that may be essential during the pandemic, ultimately making the situation worse.
We see some evidence of the public’s difficulty in grasping these concepts across the situations that have emerged since the lockdown, for example panic buying, increasing stigma, anxiety and frustration, the exodus of labourers from cities after the lockdown, and people crowding streets to bang plates, etc.
To enable behavioural change in the public, we need to understand individual (beliefs, motivations, biases, etc.) and group level factors (group dynamics, peer influence, cultural beliefs, public trust, etc.) that can influence our judgment and decision making. Understanding of these factors is achieved through systematically studying how different individuals perceive risk and what prompts them to act upon it. Some of the seminal work in this field by Daniel Kahneman, Amos Tversky and other researchers present substantial evidence of the heuristics and biases people use to make judgements and decisions. This body of research has consistently shown that people’s decisions are swayed by factors such as their beliefs and emotions, and which often ignore logic and facts, even during peaceful times. Such tendencies will be further enhanced during a pandemic.
Beyond effective communication and immediate behaviour change (such as physical distancing), there are other critical SBS aspects that need to be studied and understood for their impact on people during this unprecedented crisis. These include growing stigma associated with healthcare professionals, people exposed to the virus, the adverse mental health issues due to social and economic costs, role of communities, etc.
These adverse events are a consequence of the restrictive policies (such as quarantine, lockdown), misinformation, ineffective communication and poor health literacy, and using SBS research and evidence to inform policy and interventions can mitigate some of these effects. A review article recently published by The Lancet reports that the psychological impact of quarantine includes post-traumatic stress, anxiety, depression and public anger.
While there is evidence of successful strategies from previous public health campaigns using SSIs, such as using graphic imagery in the anti-tobacco campaign, and reducing stigma associated with HIV/AIDS patients by awareness campaigns involving celebrities. Such approaches when broad-based and integrated into public health will be most impactful. These approaches work best in tandem with social protections and policy measures that help alleviate some of the inevitable social and economic distress.
As the COVID-19 pandemic evolves and worsens without any visible respite, sustaining these social interventions is critical. It is important to engage with the community to ground our pandemic response in the social, cultural and ecological contexts to reinforce their long-term participation. We need creative ways to build community resilience, evolve models of care, social support and solidarity.
While there has been a considerable and understandable push for biomedical research to help us deal with COVID-19, it is important to invest in public health research with a particular emphasis on social and behavioural approaches and methods for a holistic response. It is critical to focus on a collaboration and real-time integration of interdisciplinary approaches involving epidemiologists, social and behavioural scientists and other disciplines in designing innovative, rapid, culturally sensitive and precise public health interventions to respond to crises and also enable us to be better prepared for such public health emergencies in future.
Gowri Iyer is a cognitive and behavioural scientist and Nanda Kishore Kannuri is a medical anthropologist, both at the Indian Institute of Public Health, Hyderabad. The views expressed here are the authors’ own.