Dispatches from the Behavioral Scientists Fighting Coronavirus in the Global South

We are in the middle of a global pandemic, one that has infected more than 35 million people worldwide and killed over 1 million. Almost nine months after the World Health Organization declared the novel coronavirus a “public health emergency of international concern,” the primary strategies we have to prevent the spread of an invisible and often deadly virus are behavioral—keeping a distance, wearing masks, washing hands. No wonder behavioral science has been thrust into the spotlight. Behavioral scientists have been advising national and local governments, as well as health institutions around the world about the best ways to help people collectively adhere to new behaviors.

Although the pandemic rages globally, 7 of the 10 worst outbreaks in the world are in countries in the Global South. These countries have very different social, cultural, and economic contexts from those in the Global North. Mitigating the pandemic in these countries is not simply a matter of importing recommendations from the north. As Saugato Dutta pointed out, “advice that can seem grounded in universal human tendencies must be careful not to ignore the context in which it is applied.”

What are the elements of context that we need to attend to? What issues are behavioral scientists in Nairobi or New Delhi grappling with as they tackle the virus? What can we learn from the interventions deployed in Brazil or in the Philippines? And how can these lessons inspire the rest of the world?

We thought the best way to understand these questions was simply to ask behavioral scientists in those countries. And so, in this special collection, we have curated dispatches from behavioral scientists in Africa, Asia, the Middle East, and South America to learn what’s different about tackling coronavirus.

Our goal is to learn from the work they have done, understand the unique challenges they face, and get their view on what behavioral science needs to focus on to benefit the 80 percent of the world population that lives in these countries. We also hope that this collection will spark ideas and seed collaborations among behavioral scientists in the Global South and North alike. The current situation demands it.

— Neela Saldanha & Sakshi Ghai


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The diverse themes that emerged in this collection are by no means exhaustive, and we recognize unexplored, critical challenges are springing up each day. Share your ideas and experiences by emailing us at editor@behavioralscientist.org.


Africa

SOUTH AFRICA

Harnessing Ubuntu
Rochelle Jacobs

In Africa, self-isolation consequences go beyond distress: the idea of social distancing clashes with our very identities.

Ubuntu—translated as “I am because we are”—is a fundamental principle of humanity for many in Southern Africa and is a pivotal component of South African public policy. In practice, ubuntu means supporting family financially, showing compassion and being active in the community, inviting others into your home with open arms, and caring for the ill and elderly.

How do we work with, rather than against, deeply rooted cultural constructs, like ubuntu, to build more relevant behaviorally informed messaging around new behaviors like social distancing?

In cultures and contexts where communities draw together during crisis, telling people that isolation is an act of humanity contrasts with their existing beliefs of what it means to be human.

With cognitive dissonance comes tension, anger, and low compliance to self-isolation measures. How do we work with, rather than against, deeply rooted cultural constructs, like ubuntu, to build more relevant behaviorally informed messaging around new behaviors like social distancing?

Rochelle Jacobs is a behavioral science consultant and analyst at Cenfri.


SOUTH AFRICA

How risky is COVID-19 if you’re already facing other threats?
Natan Sklair

In South Africa, high inequality means designing interventions for what are effectively two economies. On the one hand there is a Global North-analogous wealthy minority. On the other hand, there is a majority who are subjected to poverty and face higher mortality risks, as a result of higher rates of violent crime, poor access to quality healthcare, and other affordability constraints (taking public transport vs. driving).

Given that people in developing economies face a crude death rate that is 3.3 percentage points higher than the rate for those in developed economies, their marginal risk of COVID-19 is lower.

With this in mind, interventions aimed at encouraging adherence to COVID-19 precautions must account for differences in mortality risk perception. Taking people’s context into account, interventions can be designed to target fewer, but more influential behaviors.

For populations that are used to risk, interventions that focus on action, rather than individual risk, may be more effective. For example, older people are deeply respected in many African countries—messages that make salient the impact on one’s elders may be worth testing. Another solution may be to encourage people to speak up when people don’t adhere to guidelines—similar to how taxi drivers in Kenya drove safer when their passengers were encouraged to “heckle and chide.”

Natan Sklair leads the Behavioural Economics Team at Old Mutual Limited, one of Africa’s largest and oldest financial services firms.


NAIROBI, KENYA

The challenge reaching vulnerable populations
Mareike Schomerus

When COVID-19 hit, we, at the Busara Center for Behavioral Economics, wanted to record how vulnerable populations in Kenya were affected by social distancing measures. We conducted a survey in Nairobi’s Kibera district—Africa’s largest urban slum with about 250,000 residents—in May 2020 and learned how devastating the impact of COVID-19 has been. Almost 70 percent of respondents had gone without food or water due to social distancing. We were also shocked by the extent of mental health issues: a quarter of our respondents exhibited symptoms of poor mental health nearly every day. We also found a statistically significant correlation between the perceived likelihood of physical violence and economic impact.

The most vulnerable simply cannot afford the time and resources needed to participate in research … Tackling COVID-19 in the Global South requires paying heed to who provides information that shapes the government and organizational responses.

These insights are only the tip of the iceberg. A critical underlying issue is: Who gets to share their experiences with researchers? The most vulnerable simply cannot afford the time and resources needed to participate in research or may not want to participate given substantial risks of being identified. In our sample, more than 86 percent of those participating had not been surveyed about COVID-19 before. Nearly half of the women in our sample perceive a “very high” likelihood of physical, verbal and sexual violence—much higher than more representative surveys conducted by the World Bank, which reported around a 5 percent increase in “fights in the household.” It’s not clear whether our population is facing different issues (or being weighted more heavily in our sample) or if the broader national representation may hide areas for real concern.

Going forward, tackling COVID-19 in the Global South requires paying heed to who provides information that shapes the government and organizational responses.

Mareike Schomerus is a vice president at the Busara Center for Behavioral Economics.


CAPE TOWN, SOUTH AFRICA

Reliable data is always a challenge. In the Global South, even more so.
David Perrott

Managing the virus requires good decision-making, which in turn requires reliable and relevant data, and plenty of it. Without this data, we are wading through high levels of uncertainty, throwing darts into the darkness, hoping they’ll hit the mark, but never really knowing if they do.

The Global North has plenty of data issues. Yet these countries’ data challenges pale in comparison to what is being faced in the Global South. While Australia, Canada, and the United Kingdom are trying to find the best ways to improve the adoption and usage of mobile tracing applications, most individuals in countries throughout Africa still don’t own a smartphone. Any discussion that involves Bluetooth, NFC (Near Field Communication), or GPS is a nonstarter.

COVID-19 has highlighted quality data as the fundamental constraint to doing effective behavioral science, and in my view, it is this above all else that is holding the discipline back in the Global South.

Data infrastructure on its own isn’t enough to do effective behavioral science. But without it, you have no chance. To use a timely metaphor of baking in quarantine, it is like trying to accommodate for not having yeast by adding more flour to the dough. It just isn’t going to work.

COVID-19 has highlighted quality data as the fundamental constraint to doing effective behavioral science, and in my view, it is this above all else that is holding the discipline back in the Global South.

David Perrott is an applied behavioral scientist working from Cape Town, South Africa and he also runs a global online program called Circles in Time.


WESTERN CAPE, SOUTH AFRICA

A shadow pandemic: Gender-based violence
Ammaarah Martinus and Cameron Cyster

In South Africa, reports of gender-based violence doubled during the first three weeks of lockdown. Our team at the Western Cape Government believed that behavioral science would provide a useful lens to address the issue, but examples of effective behavioral initiatives in the gender-based violence space proved to be relatively thin.

Once we started breaking the problem into smaller chunks, opportunities for intervention became clearer. We recently spoke to some NGOs and women’s shelters to understand underreporting in the Western Cape. The findings included:

  • Women in poorer areas most often used informal channels for reporting (soup kitchens) instead of formal channels (national call center)
  • Victims perceived reporting abuse as secondary to basic needs (food, health, shelter, income)
  • Many women did not know they could report during lockdown, and when they did report they were often turned away as police were occupied with COVID-19 issues

COVID-19 has emphasized the need to ensure clear, behaviorally informed communication about government services and for the government to know where its shortcomings are in providing these services. Going forward, tackling gender-based violence from a behavioral perspective will be of paramount importance, starting with examining service delivery bottlenecks and then seeing how to address negative social norms around this issue.

Ammaarah Martinus is the director of policy research and analysis at the Western Cape Government, South Africa.

Cameron Cyster is a policy and strategy researcher in the Western Cape Government, South Africa.


Asia & the Middle East

NEW DELHI, INDIA

Enforcing norms without vigilantism
Pooja Haldea and Pavan Mamidi

Ensuring large-scale behavior change among the 1.3 billion people of India can’t be left to formal institutions alone—we need to introduce new social norms for adopting simple protective behaviors such as mask wearing. Previous research has shown that third-party sanctions are critical to the existence of social norms. In an atmosphere of high fear and existing class dynamics, how can we respectfully remind others and enforce the norm without resorting to vigilantism?

In an atmosphere of high fear and existing class dynamics, how can we respectfully remind others and enforce the norm without resorting to vigilantism?

Class dynamics play out in the form of a feudal mindset that the poor bring in infectious diseases. If disease breaks out in a household or a neighborhood, the blame is quickly ascribed to the outside help, which could worsen the situation, even though in the case of COVID-19, the opposite has been true.

At the Center for Social and Behavior Change, we are focusing on communicating social norms using what we have termed the 4Rs framework: Responsibility, Reminders, Reprimand, Respect. Each person needs to be responsible for compliance and enforcement. People need multiple reminders as norm noncompliance is often a function of forgetfulness. Noncompliers need to be reprimanded respectfully—and people may need a script to help them do so. We are actively testing how this framework can be deployed in the context of the coronavirus.

Pooja Haldea is a senior advisor and Pavan Mamidi is director at the Center for Social and Behavior Change at Ashoka University.


INDIA

A case for decentralized nudging
Anirudh Tagat and Hansika Kapoor

India is home to 22 official languages, at least seven religions, and various sects within each of these. An Indian residing in urban Mumbai differs substantially from another residing in rural Bihar. In the context of COVID-19, social norms might vary hyper-locally—the acceptable level of mask wearing or social distancing differs depending on the state, city, or even housing complex in which one resides. A behavioral unit that is too centralized may be unable to provide recommendations specific enough to be effective given India’s level of diversity.

A behavioral unit that is too centralized may be unable to provide recommendations specific enough to be effective given India’s level of diversity. What if we decentralized nudging?

What if we decentralized nudging? We know from prior experience on boosting voter registration rates in Mumbai just how important collaborating with local institutions is. In the fight against COVID-19 in India, civil society organizations, grassroots NGOs, and resident welfare associations may hold the key to effectively implementing and monitoring behavioral interventions. Specifically, resident welfare associations can enforce context-appropriate sanctions and norms in terms of hygiene, cleanliness, and mask usage.

A challenge we face in India in implementing this approach is that we need more trained behavioral scientists and more collaborators to be familiar with integrating behavioral insights into their work.

Anirudh Tagat and Hansika Kapoor are researchers at Monk Prayogshala.


MIDDLE EAST

The benefits to overcoming the stigma around reporting
Fadi Makki

During the early days of the COVID-19 outbreak, the stigma of reporting initial cases was high in Arab countries. The incidence of underreporting confirmed cases and deaths remained significant, even after the WHO declared COVID-19 a global pandemic and the region reported its first coronavirus cases. At play were anxieties and shame stemming from stigma (relevant in the Middle Eastern context, where reputation is held in high regard), which influenced government officials’ perceptions about the spread of the virus and their ability to control it.

Most countries did not impose strict measures immediately to contain the virus, as they attempted to portray an image of having the situation under control. However, some countries felt increasingly comfortable reporting on their first confirmed cases. In fact, Qatar was the first country to report the highest number of infections in one day, early in March. A few days later, most Arab countries introduced their strictest measures and began reporting higher numbers of daily cases without much stigma. In that sense, Qatar was the first mover that triggered other countries to update their norms and act on revised risk perceptions—a concept well illustrated in Cass Sunstein’s recent book How Change Happens. This highlights the importance of quick responses to crises by countries that have the potential to become vanguards and influence regional action, in a strongly collectivist society that adheres to communal traditions.

Dr. Fadi Makki heads B4Development Foundation (formerly the Qatar Behavioural Insights Unit) and is the founder of Nudge Lebanon.


INDIA

How salient is the risk of COVID-19 to already vulnerable populations?
Pratyasha Rath and Jafar Baig

Communities in the global south face significantly more threats and risks in their everyday life: communicable diseases, lack of access to healthcare, lack of basic resources like water, and loss of livelihood. Our research has shown that in the presence of continuous stressors and risks in the environment, risk perception towards some threats gets dampened.

In this population for example, young children falling sick very often is seen as a normal occurrence by mothers. Over time, in the presence of more frequent and salient risks, events like these get coded as low risk. Further, health risks are traded off not only against other health risks but against work, finance, interpersonal relationships, and their social lives.

Communities in the global south face significantly more threats and risks in their everyday life: communicable diseases, lack of access to healthcare, lack of basic resources … The current pandemic may not stand out as an extraordinary risk event.

The result of exposure to multiple risks is that the current pandemic may not stand out as an extraordinary risk event, especially when there are significant economic costs—such as loss of livelihood—to preventive behaviors. A critical area of research would be to understand how people trade off multiple risks. We will then be able to better tailor risk messaging to vulnerable populations.

Pratyasha Rath is a senior associate and Jafar Baig is a behavior architect at Final Mile.


ZAMBOANGA DEL NORTE, PHILIPPINES

Encouraging handwashing in schools: Some lessons
Crystal Haijing Huang

In schools in Zamboanga del Norte, Philippines, my colleagues and I at IDinsight recently designed and evaluated the impact of school-based behavioral nudges for handwashing. We conducted this research a few months before the pandemic hit—a situation that has only added to the importance of encouraging good hygiene behavior.

The nudge package comprised contextual cues and visible reminders. We painted a footpath that brought kids from the toilet to the hand-washing area, and once they were there, we opted for a light-touch arrow sticker pointing to the soap dish to make the specific behavior of handwashing more salient. We also added posters and eye stickers to the sink area. The intervention was effective at increasing handwashing rates after toilet use among primary school students from 12 percent in control schools to 29 percent in treatment schools. Soap availability and bucket water supply also increased due to the nudges, likely because they spurred teachers to more diligently replenish these items. Overall, the intervention cost about $70 USD per school.

We are now advising the Philippines’ Department of Education to implement the nudge package after COVID-19 quarantines are lifted. Schools in other settings may also consider incorporating nudges like these as part of reopening plans.

Crystal Haijing Huang is an Economist at Idinsight.


South America

RIO DE JANIERO, BRAZIL

A natural landmark provides a vivid, shareable reminder to socially distance
Rafaela Bastos

Within the Rio de Janeiro City Hall sits the first applied behavioral science unit in Brazilian government—NudgeRio. In March 2020, the NudgeRio team planned a nudge involving municipal public servants in their first week of quarantine to encourage social distancing.

Rio residents love for their city, so we decided to use Rio’s landscape to help. A research review brought to our attention that the image of flattening of the contagion curve matches one of the most famous Rio landmarks: Sugar Loaf Mountain. We superimposed both images (the “flatten the curve” graph and the local landscape) to create a graphic piece that would be distributed to public city servants.

We sent this through WhatsApp, a popular service in Brazil with around 100 million active users per month. Our audience received a brief text that asked them to share it with friends and family. In just a few hours, the image popped in several different social networks, reaching thousands of people and reminding them to distance and “flatten the curve” in a way that was vivid and locally understandable.

The core of the message can be summarized as: “Rio de Janeiro is giving you a hint: let’s flatten the curve.”

Rafaela Bastos is a behavioral economist at NudgeRio and branding specialist for public policy.


SÃO PAULO, BRAZIL

How São Paulo’s behavioral unit has been dealing with COVID-19
Flora Finamor Pfeifer

With over 12 million people, São Paulo is the biggest city in Brazil and one that has struggled to comply with recommended preventive behaviors of COVID-19. Since 2018, the city’s innovation in government lab, (011).lab, named for São Paolo’s area code, has been applying behavioral science to municipal challenges. Now, we had an urgent challenge: to encourage people to wear masks and practice social distancing.

We implemented a randomized controlled trial to see whether behaviorally informed text messages would be an efficient tool to communicate with citizens. Our treatment had four text messages per person that informed, instructed, and motivated the designed behaviors. The motivational messages (two of four) had five varieties: civic duty, social norms, self-efficacy, risk perception, and reciprocity towards health workers. We measured results through a telephone survey, asking citizens about beliefs, comprehension, and self-reported behavior.

Receiving the treatment seems to have had a positive impact on awareness levels (reporting correctly that one should keep a two-meter distance from others) and on mask wearing (they were more likely to report that they always wore a mask when in public). The civic duty message appeared to be the most effective and, therefore, was the motivational message that we scaled. As of writing, over 8 million messages have been sent to about 2.7 million people, prioritizing those who live in regions with the highest incidence coefficients of COVID-19 in recent weeks.

Flora Finamor Pfeifer (@FinamorFlora) is a behavioral scientist at (011).lab, the innovation in government lab based at the Innovation and Technology Municipal Department in São Paulo, Brazil.


BOGOTÁ, COLOMBIA

#JuntosNosCuidamos—We protect each other
Andrés Casas and Beatriz Helena Vallejo

By May, Bogotá, Colombia—one of the world’s megacities, with nine million inhabitants residing across a sprawling 613 square miles—had one of the lowest deaths per million inhabitants for similar size cities. People responded to Mayor Claudia Lopez’s call to action by complying with two specific collective goals: hospital ICU occupancy rate had to remain below 70 percent and the city’s bus system had to cap the number of riders at 35 percent in order to ensure adequate social distancing.

Compliance with stay-at-home orders and a 96 percent rate of using face masks was supported by the behavior-change tools. The mayor launched a collective-care narrative that focused on communicating the importance of safeguarding one another. The rallying message was #JuntosNosCuidamos—we protect each other.

Additionally, we at the Citizen Culture Direction tested eight types of messages in a randomized controlled trial. Our goal was to identify the most successful messages to reduce cognitive biases that might get in the way of people’s positive behaviors, in order to help inform Bogotá’s communication strategy. Messages that emphasized family costs and elicited positive social norms were effective in increasing risk aversion (from 24 percent to 30 percent), while those depicting the increased risk of living in specific areas of the city backfired. Messages emphasizing individual agency and depicting a mental model on how the virus operates reduced optimism bias around contagion (from 16 percent to 8 percent) and increased positive health attitudes (from 24 percent to 27 percent).

As Bogotá gradually reopens, behaviorally informed communications will continue to play a role. Encouraging ongoing preventive behavior while restrictions relax is our next challenge.

Andrés Casas and Beatriz Helena Vallejo are behavioral change advisors to the Citizen Culture Direction of the Government of Bogotá, D.C.


SANTIAGO, CHILE

Will people revert to traditional gender roles in the household?
Denise Laroze

A key element in dealing with this pandemic is trust. Trust in other people, in governments in the welfare system to provide enough to cover basic needs, in the healthcare system. In the Global South, particularly in times of crisis, it may be rational not to trust the State to take care of basic needs but instead fall back on traditional family roles.

One such role is of the traditional provider, typically filled by men, who go out to work, shop, and interact with the dangerous outer world. Women then, play the role of carer, at home looking after the family in a protective quarantine bubble.

If COVID-19 leads families to revert back to these traditional roles, it could have consequences for women’s opportunity for work outside the home.

If COVID-19 leads families to revert back to these traditional roles, it could have consequences for women’s opportunity for work outside the home.

In a survey conducted in April 2020, 61 percent of the sample (designed to represent the Chilean population in quarantine) reported a gender bias in household chores (childcare, education, cooking, cleaning, laundry, shopping). Across five out of six chores, a majority of women reported they were the only ones in their household responsible. In only one—shopping, a standard “provider” role—did a majority of men declare that they were the only ones responsible for the chore.

We also see a gender imbalance in the labor market. As of July 2020, 23 percent of women and 17 percent of men have lost their jobs in Chile. Occupation levels are at record lows, with only 41 percent of women and 63 percent of men in the workforce, roughly 10 percentage points lower than the pre-pandemic levels.

Behavior has a tendency to be sticky. One wonders how easy it will be to reverse these roles when the pandemic ends and what the consequences they’ll have on work in and outside of the household.

Denise Laroze is an associate professor in the Department of Management and Center for Experimental Social Sciences at the Universidad de Santiago de Chile.


LATIN AMERICA

The importance of trust in government
Margarita Gómez-Garcia and Lucía Macchia

In many Latin American countries, citizens lack trust in their government. In addition to the structural and economic limitations that many Latin American countries are facing, such as a large number of people working in the informal sector and living in poverty conditions, lack of trust in government makes the fight against the virus even more difficult. Citizens’ trust in government is key to promote adherence to governmental measures designed to protect public health. Insights from behavioral science can help to increase this trust. To make their response to the pandemic more effective, these countries should focus their efforts on three main areas:

  1. Leverage trust at the community level to motivate individuals to comply with government’s recommendations
  2. Communicate clear and timely information to reduce people’s uncertainty
  3. Use behavioral messages to nudge groups of people according to their specific needs 

Margarita Gómez-Garcia is the inaugural executive director of the People in Government Lab at the Blavatnik School of Government in Oxford University.

 Lucía Macchia is a postdoctoral research fellow at the Women and Public Policy Program at the Harvard Kennedy School.



Conclusion

We are heartened by the breadth of behavioral science being applied to tackle the coronavirus around the Global South. From these dispatches, we learned about critical issues facing the Global South: improving trust in government institutions, reporting gender-based violence, getting better data, reaching vulnerable populations, and understanding how cultural factors like stigma play a role in reporting. We are also inspired by the creativity and the potential for innovation, illustrated by local landmarks in Rio, beliefs like ubuntu in South Africa, or school-based nudges in the Philippines.

We see a consistent call for more contextualized, hyper-local, citizen-led behavioral interventions, supported by reliable data. This requires trained behavioral scientists not only in the North-South, but even more critically at the South-South level to build a collaboration that fosters mutual learning.

We hope that this initial collection will encourage more voices in behavioral science in the Global South to step forth and stimulate much needed discussion on how we can use our incredible diversity to battle a common enemy, while at the same time making our science truly inclusive.