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Changing health beliefs and behaviour during the COVID-19 outbreak in Pakistan

Incorporating behavioural add-ons in public health appeals to slow the spread of COVID-19.

Microfinance borrowers taking their loan sums from a mosque in Pakistan. Credit: Mr Saad Rashid.
Microfinance borrowers taking their loan sums from a mosque in Pakistan. Credit: Mr Saad Rashid.

Attenuating the spread of COVID-19, flattening the epidemiological curve, has become the key priority of governments across the globe. While many Western-European governments have enforced complete lockdowns, governments in developing countries have tended to rely upon information campaigns to increase awareness of the virus. This dichotomy reflects that some governments cannot finance mass income support schemes. 

In the absence of lockdowns, it is critically important to sensitise the public about precautionary measures individuals can take to reduce the spread of the virus - a fact that is particularly prevalent in Pakistan, where the Prime Minister has all but ruled out a lockdown. Instead, the virus will be combatted by information campaigns aimed at engendering high levels of compliance with health advice by the general population.

Our research presents evidence of a simple information intervention that improves COVID-19 knowledge and related behaviour in Pakistan. Moreover, it is low cost and easily replicable. The solution presented in this paper is simple: an SMS message documenting the main symptoms of the virus and steps to reduce its spread combined with a behavioural add-on.

The Mind and Behaviour Research Group at Oxford have posited several behavioural add-ons to increase the comprehension and adherence of health advice during the pandemic. Moreover, the U.K. government have incorporated behavioural scientists in the implementation of important policies for more than a decade now. Our project in Pakistan builds on this field by incorporating religious authority into the health appeal.

Experimental evidence substantiating the effectiveness of the religious add-on comes from a randomised control trial, issued this August in Pakistan. 7,000 Akhuwat clients, Pakistan's largest microfinance provider, were randomly divided into six treatment groups and one control group. Each group consisted of 1,000 microentrepreneurs. Those in the treatment groups received an SMS with the same COVID-19 health advice from the World Health Organisation (WHO). The SMS documented the three main symptoms of COVID-19 and five mitigation steps to reduce the spread of the virus. Notably, the treatment SMSs only varied in their first sentence.

In the religious treatment, clients received health advice with a religious introduction, specifically, ‘Allah's beloved Prophet Muhammad (PBUH) taught us that cleanliness is half the faith.' This treatment path increased the number of mitigation steps people took to avoid infection by 35.3% and improved knowledge of COVID-19 symptoms by 6.4% compared to those who received no SMS. Additionally, the likelihood that a respondent would stay at home if they were experiencing symptoms of the virus increased by 8.6 percentage points.

A series of benchmarking interventions unequivocally show that religious appeal is most effective in the Pakistani context among the multiple introductions tested in this experiment. The results also underline the importance of behavioural add-ons in the COVID-19 response since an SMS without an introductory sentence had no significant effect on the number of mitigation steps taken, nor on the number of symptoms known. 

Overall, the findings provide experimental evidence that a simple information intervention can impact health and behavioural knowledge if combined with the correct add-on for the context. These findings suggest that health campaigns appealing to the religious identities of recipients are more likely to be successful in Pakistan, which has stark policy ramifications during the COVID-19 pandemic. Firstly, this research offers a solution to maximise compliance with government COVID-19 advice given fiscal constraints immediately. And secondly, the project provides insights to increase uptake of any potential vaccine in the future. 

This study is ongoing with more data expected in early 2021. 

Contact: Jordan Barnard:

Acknowledgements: I would like to thank the CEO of Akhuwat Foundation, Dr Amjad Saqib, for his generous support in facilitating this research. The Board and staff of Akhuwat have helped the research team overcome the huge logistical challenges faced when conducting 7,000 surveys across every province in Pakistan.

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