What do the Wizard of Oz, a lion, a scarecrow and a tin man have to do with the road to recovery from COVID19?

At the end of June, our Founder Luke van der Beeke joined Victoria’s Chief Health Officer, Professor Brett Sutton and health economist, Professor Jonathan Karnon to answer the question: Will the road to recovery be paved with casualties?”

An abridged transcript of Luke’s presentation is provided below. The webinar was hosted by The Health Issues Centre of Victoria.

The road thus far

Each country’s experience of COVID has been different. This is in part due to the relative effectiveness of government responses, but it is also a function of other contributing variables which impact the virus’ ability to spread. People’s behaviours (do they self-isolate, do they test when symptoms arise, do they comply with social distancing rules) are perhaps the most significant of those variables.

In relative terms Australia has fared well. The response from federal and state governments has been generally been very good. For some, their government’s response has served to rebuild trust. That said, it’s also fair to say that Australia has once again earned a reputation as the lucky country.

COVID presents government and civil society with unprecedented health, social and economic challenges. At the heart of these challenges are human beings, and we are fickle creatures. Our attitudes shift and change quickly over time, and as a general rule of thumb, our behaviour is predictably irrational. (For more on that read Dan Ariely’s excellent book Predictably Irrational)

Commercial marketers have leveraged people’s predictable irrationality for years to influence consumer behaviour. Regrettably, this knowledge has historically been used to leverage behavioural biases which result in people consuming products that are bad for them or the planet.

For example, commercial marketers know one reason we’re prepared to consume products that do us harm is that we tend to discount the future costs of doing so. The immediate sense of gratification felt by eating a Mars bar or drinking alcohol with friends more than offsets the potential future cost to our health. Behavioural economists call this phenomenon hyperbolic discounting.

Thankfully, social marketers, and more recently behavioural economists, use this same knowledge to influence behaviours for good – both downstream, where efforts are made to influence individual choices; and upstream, where strategic social marketing and behavioural insights are used to inform government policy and communications.

The Wizard of AUS

I do find it hard to resist a good metaphor. Some might say that the PM (and in fairness, state Premiers) have performed acts of wizardry keeping the majority of Australians safe over the past few months. So, my road to recovery is comprised of yellow brick. In order to navigate it safely, and to minimise casualties, government will need to show courage, be smart, and have a heart.

A few assumptions

1. Human behaviour and our government’s ability to manage it effectively will be a key determinant of how successful we are at navigating the road to a post-COVID world.

2. There is also an assumption that we’re now actually on a road to recovery. I’m not so sure. Global cases continue to rise exponentially and a vaccine may be months or years away. Furthermore, political and economic pressures may lead to the opening of borders and easing of restrictions well before it is completely safe to do so.

Notably, Australian commentators often caution the public about the risk of a second wave. This of course assumes there was a first wave. Here in Australia, that first wave was more akin to a ripple. Should a second wave come, I fear that without due consideration of the likely less compliant behavioural response from large portions of the public, it could quickly turn into a tsunami.

3. Another assumption is that adaptation as opposed to elimination remains the preferred choice as the pandemic continues to evolve. This is important for many reasons, not least of which being COVID will remain a background threat to people’s health for months if not years to come. This will impact behavioural and attitudinal responses to government efforts to reduce the impact of COVID as we make our way forward.

And of course, casualties have not, and would not, be limited to COVID related cases and deaths. Our response needs to account for the myriad other adverse impacts COVID creates and amplifies, including mental health, economic hardship, health inequalities and domestic violence to name just a few.

4. My final assumption – pets don’t spread the virus…

The response to date

Susan Michie’s Behaviour Change Wheel (below) is useful because it highlights sources of behaviour (based on the COM-B model), as well as intervention functions and policy categories.

Interventions to date (in red) have predominantly relied on restrictions (border and business closures, social distancing), education, and persuasion. Each of these interventions have been successful in large part because most Australians have had the motivation (initially fear, then concern for others, a sense of social responsibility/civic duty), capability and opportunity (green circle) to comply.

It must be said that over time the amount of conflicting and confusing messaging has increased. Complex and at times counter-intuitive policy settings on a range of issues have also started to chip-away at public confidence.

Fear

As far as motivators go, fear can be very effective. Fear appeals have been used for decades to influence people’s choices – think graphic anti-smoking ads or road safety commercials.

But not every fear appeal is successful. Just because a person is scared of something doesn’t mean they’ll behave in a way that reduces the perceived threat.

Two conditions that studies consistently link to behavioural intention are perceived threat and perceived efficacy.

In the case of COVID, the perceived threat was initially extremely high in terms of the likelihood of exposure and impact. This was helped along by cases of alarmist journalism which served to build a sense of panic.

Initially, most Australians felt they had the ability to practice social distancing and abide by restrictions to movement. But that only lasted a short while. Within weeks other concerns took hold, not least of which being the economic impact of restrictions. Covid remained cause for concern, but the loss of jobs and other impacts at home became a more prevalent attitudinal driver. As a result, people’s perceived efficacy (i.e. their ability to abide by restrictions) began to decline.

Looking forward, when the efficacy element does not overpower the source of fear (COVID), individuals may choose not to adopt a suggested response, either because they feel incapable of completing the protective action or because the suggested action will not be effective. Rather than concerning themselves with eliminating the threat, individuals may look to control their fear by avoiding thoughts about the threat or minimizing the issue.

Should a second wave arise this is something government needs to be very mindful of.

Presenting facts isn’t enough

We are moving from a system based around vertical axis of trust, where we trust people who seem to have more authority than we do, to one predicated on horizontal axes of trust: we take advice from our peer group.

Gillian Tett, Financial Times, July 01, 2016.

Whether we’re hit by a second wave or not, the optimal road to recovery will require an understanding of what drives human behaviour. Sadly, as recently observed by a colleague of mine, Professor Jeff French… “we remain far more adept at counting the sick and the dead and reporting facts than we are at understanding what truly moves and motivates the people we purport to serve.”

The truth of this statement is evidenced in many ways, including how we engage (or fail to engage) with communities and the persistent top-down approach to health communications. As the road to recovery winds on, presenting facts and expecting people to change their behaviour because an expert say it’s in their best interests simply won’t suffice.

For the past few decades democracies have been moving away from vertical axes of trust. Citizens tend to pick and choose what information they believe based on their own pre-existing views. It’s called confirmation bias and the impact it’s had on our political and social fabric can’t be overstated.

This brings me to the three central characters in my metaphor – the lion, the scarecrow and the tin man. I think they have the attributes needed to ensure a successful road to recovery.

The lion – COURAGE

Governments must be courageous, and that means being open and transparent with the public. During a pandemic like COVID, which threatens so many lives, there is an ethical obligation on government to provide all relevant facts so that people can make truly informed choices. Thankfully, this openness and transparency is already evident in most jurisdictions, but it must be remembered that “shared responsibility” is a two-way street.

During the first few months of the pandemic some messages were framed in ways that were misleading. For example, misleading information was provided about the level of protection afforded by face masks. Statements about the safety of children attending schools were also not entirely evidence-based.

Finally, debate and responses to questions from the press (and others) tend to be characterised by repeated assertion of talking points to which factual rebuttals are often ignored. Governments need to be courageous enough to listen and respond to questions openly. The press could help by adopting a more measured, balanced approach to questions so as not to force politicians onto the defensive.

In many respects, despite all the negatives, COVID provides government with a unique opportunity to rebuild lost trust, and reframe its relationship with the public. Early signs are some jurisdictions are doing it better than others.

The scarecrow – BRAIN

The collection and use of reliable data in terms of contact tracing, community spread, and behavioural intent will remain critical as Australia’s COVID journey unfolds.

For example, the WA Government’s DETECT Snapshot program, which ended last week, failed to find a single case of coronavirus from more than 16,000 targeted tests of frontline workers. This has boosted local confidence that there are no hidden pockets of COVID infection in the community and will be used to inform policy adjustments, particularly around social gatherings.

Notably, the COVID safe app has been plagued by technical challenges, and as perceived risk has fallen the number of people downloading the app has done so too. We’re still about 1.5m below the 40% download target, and Australians are more supportive of using telecommunication company metadata (79%) to track close contacts than they are using the app (70%).

Reshaping environments to make it easier for people to practice physical distancing will remain useful. Even simple behavioural prompts can be very effective.

The public is more intelligent than some like to think. It’s also worth considering that many people don’t solely rely on government messaging to inform their behavioural choices with regard to COVID. So, messages need to be consistent across all Australian jurisdictions. Our response should also account for the impact that information originating from other sources (credible or otherwise) has on shaping people’s attitudes and beliefs.

The tin man – HEART

Our final character is the tin man.

There is a great deal to be gained through effective and appropriate application of behavioural insights, behavioural design, and data-informed interventions. That said, I also believe that to affect sustainable change, governments need to act with heart.

Will the road to recovery be paved with casualties? It’s hard to tell. What is certain is the socio-economically disadvantaged will be at greater risk from the direct and indirect impacts of COVID. A recent UK study found that the mortality rate of deaths involving COVID in the most deprived areas is 2.3x that of the least deprived.

While politics and health will always be intertwined, it will be important to ensure that the politics of health doesn’t lead to unnecessary casualties as we navigate our way through the new normal.

Health literacy is also a challenge for many Australian health consumers. It’s in this context that governments (State and Federal) need to convey essential health information to the public.

Many in Culturally and Linguistically Diverse (CaLD) communities, including a large number of older Australians, source their information from other community members and service organisations. Social distancing and organisational closures results in large numbers of people without access to their trusted information sources. We must ensure measures are in place to account for this.

If we want people to change their behaviours we need to ensure they understand what we’re asking them to do. We also need to help people do it. When asked how government should encourage adoption of new behaviours, 68% of respondents to a University of Washington survey said they wanted to be helped to do it (see figure below).

We also need to confer agency to the public and provide opportunities for people to actively contribute toward fighting the virus. This has the added benefit of helping to combat any sense of hopelessness which were seen in some areas during the lockdown. This will be particularly important should a second wave eventuate.

Final thoughts

The road ahead is uncertain and will be unique for each Australian. Government has the unenviable task of laying each (yellow) brick with the ultimate aim of leading the country to a full recovery.

As the journey unfolds, attitudes and behaviours toward COVID will change. While many are now applauding the success of preventative health measures there are others who believe we overreacted, due in large part to the very success we’ve had.

The relative success of Australia’s response has already led to complacency, If a second wave hits (and it almost certainly will) there’s a real danger people will be less willing to comply with physical distancing and self-isolation measures.

Government needs to consider this now, and future behaviour change strategies may need to be a little different to what we’ve seen thus far. For example, more controls may be necessary as voluntary compliance wains.

My final observation is that when many Australians were at their most vulnerable we were afforded a glimpse of just how good the new normal could be.

Whether our collective experiences to date are enough of a disruptor to completely break old habits remains to be seen. But has there been a shift in values? I’m not sure.

What I do know is that no matter what challenges we face on the yellow brick road to recovery, if we approach each one of them ethically and draw on evidence and lived experience to formulate our approach we will minimise the number of casualties along the way.

I want to end with a fantastic ad out of New Zealand that seeks to build social solidarity. It’s something we’ll need here in Australia too as our journey along the road to recovery continues.

If you’d like a copy of the slideset feel free to get in touch with me via email.

Watch the webinar…