The COVID-19 pandemic has brought a dual health and economic crisis to our doorsteps. Having spent the past several years leading complex behavior-change interventions, I have several insights that can inform a robust COVID-19 response.
Behavior change—people practicing physical distancing, handwashing, coughing into their elbows, and remembering not to touch their eyes, nose, mouth, or shake hands—is hard, and doesn’t happen overnight. Global adoption of these practices requires that we adapt how we communicate about them and undertake them in different communities and contexts. Despite the formidable challenge of widespread behavior change, right now our lives depend on it: these behaviors are our best bet for flattening the curve of COVID-19.
I currently lead Pathfinder’s (re)solve project, in partnership with Camber Collective, the International Center for Research on Women, and ideas42, which takes a nuanced approach to behavior change. (re)solve specializes in designing and testing a strong, behavioral response to changing behaviors that is informed by local norms and beliefs. Our customized, data-informed family planning solutions are specific to the needs, motivations, and lived experiences of women and girls in each of their respective communities.
Through (re)solve’s experience over the last three years, which has combined expertise from behavioral design, consumer insights, and public health, we have a more nuanced understanding of what stops women from using contraception (or using it consistently and correctly) when they express a desire to avoid pregnancy. The following learnings from (re)solve can inform responses to pandemics like COVID-19.
1. Just giving people information does not result in behavior change.
In the three countries where (re)solve works—Bangladesh, Burkina Faso, and Ethiopia—governments, international NGOs, and donors have been providing information about contraceptives for decades. Yet, the unmet need for contraception has remained high, especially in Burkina Faso. Here, we learned that young, sexually active, unmarried girls do not think they are at risk of an unintended pregnancy because they track their periods (not always correctly, according to our data) and don’t feel the need to use a modern contraceptive method. We know that how girls perceive pregnancy risk plays a significant role in whether they use a contraceptive method or not. So, in Burkina Faso, we designed a behavioral science-backed game that elevates and corrects their risk perception, giving girls a chance to discuss their risks, behaviors, consequences, and trade-offs through examination of real-life scenarios, and illustrating the longer-term rewards of preventing an unintended pregnancy. We need to understand why people do or do not or cannot change their behavior—rather than simply assume they will make changes when given an educational or preventive message.
2. One size does not fit all, even within the same population.
We learned that we have to go under the surface, even in demographically similar populations, to find out what drives behavior change. For example, we learned that married garment workers in Dhaka between the ages of 18-45 years had very different fears and barriers influencing their own contraceptive use. Some felt comfortable raising concerns about side effects, while others were uncomfortable discussing concerns with their spouse, let alone health providers. Some women said they made their own decisions to use a contraceptive method, while others consulted with their husbands. Our solutions needed to address these differences; it was not a ‘one size fits all’ approach.
Similarly, we cannot assume that everyone CAN or WILL understand and practice physical distancing. It could help to clearly explain this term in local, relatable terms and concrete, doable actions (e.g., “maintain distance of two arms lengths,” “avoid going to the market,” “postpone weddings,” “cancel conferences”). In densely populated spaces, visual cues in public spaces can take the guesswork out of estimating distances.
3. We need to integrate interventions into existing tools and familiar models.
In Ethiopia, we designed solutions that can be easily understood and incorporated elements familiar to health workers and postpartum women. We designed and user tested a referral card that allows health extension workers to assess and score a postpartum woman’s growing need for family planning counseling. Women and health workers immediately recognized the escalating significance of the ‘green-yellow-red’ colors because it mimicked the colors (and the significance) of the middle upper-arm circumference band used to check for child malnutrition. The card needed little to no training — it was easily understood. The referral card also fits into the Family Health Card, a card that every pregnant woman receives and contains information about her health and the baby’s immunization history. In an emergency, we need messages and solutions that require no explanation, will not be misinterpreted, are simple to deliver, and do not require extensive training of health workers.
4. Testing messages and solutions with health care workers and the community can surface unintended consequences.
In Tigray, Ethiopia, we tested several different ideas to engage men in decisions about postpartum family planning. Health extension workers gave us candid feedback about our ideas. One of their concerns about facilitating home-based joint discussions on family planning and family health was that many women used injectables without the consent of their spouses. The joint conversations we proposed could potentially ‘out’ women, they said. User testing allowed us to elicit reactions and concerns about and we were able to discard the ideas that could have negative and unintended consequences for women.
During a pandemic, rapidly testing messages and solutions may be our greatest challenge, despite how critical it is. Early message testing would have shown, for example, that we need to exchange the term social distancing for physical distancing. While we cannot be in physical proximity to one another, during times of high stress, it is important to stay as socially connected as possible and to continue to provide social support, especially to vulnerable groups.
Physical distancing makes formative research and user testing difficult. Where people have access to mobile phones and broadband, new technologies can offer a powerful platform to “take the pulse” or to push messages as we are doing with our partners in India through the YUVAA project and analyze how people respond. In countries where we cannot use technology to gather user feedback and where physical distancing will not allow for formative research and testing, we will have to find creative ways to engage the community and test messages. We need to think about what role trusted community influencers, peers, and religious leaders play in getting messages out and gathering feedback. For example, how can local religious leaders model behaviors and test prevention messages?
4. Context matters.
We need to understand how structures, in any given context, could create barriers to behavior change. Girls in Burkina Faso told us that they don’t go to the health center for contraceptive services because they are provided in the maternity ward. Neighbors who see girls in the maternity ward could start rumors about unintended pregnancies. We designed and tested a poster that “advertises” counseling for young girls on puberty-related issues (like acne, painful periods). Girls now have a reason to be seen at health facilities without feeling shame or facing stigmatization. While we design COVID-19 messages and solutions, we must ensure that they are not inadvertently increasing the discrimination and targeting of already stigmatized groups. Stigma can prevent people from accessing health services, especially when countries are trying to increase testing.
There is so much we still don’t know: how COVID-19 will affect communities, how it will spread or be contained, how it will affect families, health care systems, and national economies, and when we can return to a sense of normalcy. Some lessons from the not-so-distant Ebola crisis maybe worth remembering and revisiting, especially innovative behavior change interventions that emerged from communities. We do not have time to test and evaluate our interventions during a crisis. Now, more than ever, we need to find creative, innovative, locally relevant messages and solutions that will stick and lead to longer-term behavior change. Understanding people’s fears, motivations, and behavioral change processes and developing targeted responses for different communities will be integral to doing so. People’s lives and livelihoods are at stake.