Can We Nudge the Pandemic Away?

ETHOS Issue 22, June 2021

Lockdowns – For How Long?

In February and March 2020, when COVID-19 swept across the globe, most countries introduced strict movement restrictions, in the form of lockdowns, to deal with the rising number of cases and avoid overburdening their healthcare systems.

But restrictions, especially if protracted, come at a significant cost. A study found that the lockdown measures imposed in Germany increased unemployment by 117,000 persons between March and April 2020,¹ while the UK lockdown from March to May of the same year coincided with the largest quarterly fall in employment in over a decade.² In Singapore, the economy contracted by 13. 2% on a year-on-year basis in the second quarter of 2020, largely due to our Circuit Breaker measures and weak external demand.³

Long periods of indoor confinement with little social interactions have also taken a significant toll on mental health,⁴ manifesting itself in the form of higher incidences of domestic violence, mental distress, and divorce.^5,6 In a number of countries, public frustration over lockdowns, mask-wearing and other mandatory safety measures have led to outward defiance, mass protests and political instability.

Governments must look beyond lockdowns and regulations to manage this pandemic, simply because these are not sustainable in the long run.

Experts are also starting to see signs of behavioural fatigue as people become more complacent about the risk of contracting the virus, or tired of observing preventative measures.⁷ This has been cited as a reason for the resurgence of the virus in Taiwan, Japan, Korea, and Hong Kong.^8,9 Mobility data in England shows that subsequent lockdowns have been less effective in getting people to stay at home compared to the first lockdown.¹⁰

This pandemic fatigue could have also posed a problem in Singapore when community cases had remained consistently low until a new wave emerged in April 2021. Residents may ease up on safe distancing measures due to fatigue or the perceived lower risk of catching COVID-19.

Unlike previous epidemics such as SARS and Ebola, which only affected certain regions and/or were contained within months, COVID-19 may well prove a long-drawn pandemic that could persist for years even with the availability of the vaccines.¹² In the meantime, residents need to adjust to a new normal of living safely with the virus.

Because of this, governments need to strike a balance between keeping COVID-19 at bay and minimising the significant costs involved in maintaining safety measures. They must look beyond lockdowns and regulations to manage this pandemic, simply because these are not sustainable in the long run. Moreover, personal hygiene behaviours such as frequent hand washing—essential elements to managing the pandemic—cannot be easily monitored nor legislated.

At the onset of the pandemic, the UK and Sweden pursued a softer approach instead of mandatory measures and lockdowns.

Can Nudges Replace Lockdowns?

At the onset of the pandemic, the UK and Sweden pursued a softer approach instead of mandatory measures and lockdowns.^1,2 They focused on recommendations and “nudges” to get people to maintain high levels of personal hygiene, maintain safe distancing in public, and avoid going out.

For example, in the Swedish city of Uppsala, signs were placed on bus doors to remind passengers to board “only if they had to”. Compliance was entirely voluntary since passengers did not have to justify their reason for travel.³ Meanwhile, the UK’s National Health Service (NHS) recommended people wash their hands while singing the Happy Birthday song twice, to improve the saliency of getting them to wash their hands for a full 20 seconds.⁴

However, it soon became clear that this softer approach was ineffective. In March 2020, the UK had to abandon this strategy and adopt a partial national lockdown to curb the escalating number of hospitalisation cases.⁵ Sweden, which stuck with its strategy for a good part of 2020, suffered a higher death rate per 100,000 people compared to its Nordic neighbours which had implemented stricter measures.⁶ It too was eventually forced to impose stricter restrictions to cope with the rising number of COVID-19 cases.⁷

NOTES

1. A. L. Sibony, “The UK COVID-19 Response: A Behavioural Irony?” European Journal of Risk Regulation, (2020): 1–8.

2. Marta Paterlini, “‘Closing Borders Is Ridiculous’: The Epidemiologist behind Sweden’s Controversial Coronavirus Strategy”, Nature, April 21, 2020, accessed April 18, 2021.

3. “Coronavirus: The Boy behind the Wash Your Lyrics Site”, BBC, March 11, 2020, accessed April 17, 2021.

4. Sarah Boseley, “NHS Hospitals Could Run Out of Coronavirus Beds in a Fortnight”, The Guardian, March 24, 2020, accessed April 17, 2021.

5. Reuters, "Fact Check: Sweden Has Not Achieved Herd Immunity, Is Not Proof that Lockdowns Are Useless", December 3, 2020, accessed May 25, 2021.

A Nudge-able New Normal?

In public policy, nudges are ways to design the context or choice environment to influence people’s behaviours in a predictable manner while preserving their freedom of choice.

Many basic measures for managing COVID-19 are behavioural changes: staying home when sick, wearing a mask, washing hands, avoiding crowds and maintaining safe distancing.

Without widely available and effective treatments or vaccines in the early outbreak, behavioural nudges were initially adopted by some countries as the primary response at the onset of the pandemic. However, this approach fell short, going by the experience of countries such as the UK and Sweden.

Experts have long argued that nudges are less applicable in cases where negative externalities are generated: i.e., when third parties who are not involved in the decision-making process of an action are harmed. This is the case for COVID-19, since people who do not comply with public health measures can harm not just themselves, but also bystanders they come into contact with. The appropriate government intervention needed in such cases has been shown to be not so much a nudge as a “shove”,¹² in the form of strict mandatory measures and lockdowns.

Nevertheless, while nudges are not in themselves a sufficient response to the COVID-19 outbreak, they can still play a useful role in the post-lockdown landscape, where the emphasis is on keeping infection numbers low in the long run. For instance, they can encourage and help sustain desired public behaviours by (a) improving compliance with public health measures in a more intrinsic manner, thereby counteracting some level of behavioural fatigue; and (b) encouraging behaviours that cannot be easily observed and legislated by public health authorities.

Nudges to Improve Compliance with Safe Management Measures

Nudges to maintain safe distancing

Researchers from the University of Bayreuth assessed the effectiveness of three different designs of floor stickers—lines (image 1); footprints (image 2); and footprints with signs (image 3) in maintaining safe distancing between customers at a store checkout area. (Click on image to see a larger version)

Image source: University of Bayreuth. Reproduced with permission.

The footprints with signs design (image 3) was the most effective at nudging customers without a shopping trolley, with 63% of them adhering to the safe distancing. In comparison, the lines (image 1) and footprints (image 2) designs achieved a compliance rate of 34% and 49% respectively.¹

Nudges to encourage hand washing

Nudges to maintain safe distancing and encourage hand washing

Efforts to encourage proper hand washing as an effective and affordable way to curb the spread of preventable diseases predate COVID-19.

In Bangladesh, an experiment to encourage good hand hygiene among students—by placing cheerful footsteps along the pathway between a school latrine and brightly decorated hand washing stations—increased the incidence of students washing their hands with soap after using the toilet from 4% to 68%.²

In a March 2020 experiment, respondents were shown seven hand washing posters designed by various health authorities and the World Health Organization. The study found posters that used bright infographic designs, accompanied with minimal text to illustrate proper hand washing techniques, to be most effective in terms of ease of comprehension, sentiments and persuasiveness.³

NOTES

1. University of Bayreuth, “How Nudging Can Help Ensure Physical Distancing”, May 28, 2020, accessed April 17, 2021.

2. Julia Rosenbaum, “Incorporating Nudges into COVID-19 Communication and Prevention Strategies”, Global Handwashing Partnership, March 31, 2020, accessed April 17, 2021.

3. Mark Egan, Abigail Mottershaw, Giulia Tagliaferri, Yihan Xu, and Vivek Roy-Chowdhury, “Bright Infographics & Minimal Text Make Handwashing Posters Most Effective—Result from An Online Experiment”, Behavioural Insights Team, March 23, 2020, accessed April 17, 2021.

Uses for Nudges in Singapore

In Singapore, nudges could support the longer-term management of COVID-19 in several ways.

Improving public communications on COVID-19

The scramble to keep up with a rapidly evolving pandemic has led to a confusing sea of shifting information, guidelines and regulations. This could lead to information overload and public confusion or mistrust. Behavioural insights could help improve the clarity and effectiveness of communication materials on COVID-19 and relevant regulations.

Making essential information more salient promotes better retention, greater public buy-in and reduced misinformation, all of which are necessary for sustaining desired behaviours.

Policymakers could explore using nudges together with the EAST (Easy, Attractive, Social, Timely) framework¹³ developed by the UK Behavioural Insights Team to improve communications related to COVID-19. Making essential information more salient promotes better retention, greater public buy-in and reduced misinformation, all of which are necessary for sustaining desired behaviours in the community.

After going through a long period of low community cases, Singapore has been seeing an increase in the number of COVID-19 community cases and new clusters in recent weeks at the time of writing this article (June 2021). This led to the introduction of additional restrictions and safeguards under Phase 2 (Heightened Alert) from 16 May 2021 to 13 June 2021.¹⁴

In a rapidly changing pandemic, it is clear that safe management measures will still be needed, and must be updated quickly to suit new circumstances. Nudges could be used in the design of communication materials to convey these changes to the public more clearly and effectively.

What is the impact of information overload?

Essential Information is Lost Amid Information Overload

UK study conducted in October 2020 showed that there were widespread misunderstandings regarding some local rules and a lack of knowledge about risk levels of various activities. For example, 19% of those surveyed did not know that indoor activities carry higher risks than outdoor activities.¹

BIT (Behavioural Insights Team) also conducted a study in Bangladesh to understand the impact of information overload on respondents’ ability to recall key messages about hand washing techniques. In a randomised controlled trial, respondents were presented with one of four hand washing posters with varying amounts of hand washing guidance. The researchers found that additional details on hand washing techniques crowded out the most basic message of the posters, which is to wash one's hands for at least 20 seconds.²

NOTES

1. Dan Brown, Stewart Kettle, and Dilhan Perera, “COVID-19 Prevention: Too Much Information?” Behavioural Insights Team, August 7, 2020, accessed April 17, 2021.

Encouraging COVID-19 Vaccination Take-Up

In Singapore, the COVID-19 vaccine is being progressively offered, on a non- mandatory basis, to those aged 12 and above (except for some subgroups such as those who are severely immunocompromised).^15,16 Nudges can be used to increase the inoculation rate among residents without restricting their choice.

Past vaccination projects show that a significant number of people who want to get vaccinated do not end up getting one for various reasons, including forgetfulness or competing priorities.¹⁷ This is what behavioural scientists call the “intention-action gap”.

A March 2021 survey found 67% of Singapore residents aged 21 and above were willing to get vaccinated and another 20% were neutral in doing so.¹⁸ However, as of 18 May 2021, only 71% of eligible seniors aged 60 and above and close to 66% of eligible individuals aged 45 to 59 years old have received the COVID-19 vaccination or booked their vaccination appointments.¹⁹

Since many Singaporeans have already indicated interest in getting vaccinated, there are plenty of opportunities to use simple, low-cost nudges to close potential “intention-action gaps” among our residents. While the demand for vaccination is now quite healthy, it will be important to prompt those who are not among the early enthusiasts to get vaccinated as soon as they become eligible.

A March 2021 survey also showed younger respondents as more likely to be concerned about vaccine safety which might affect their take-up.²⁰ Additional behavioural interventions may thus be useful as the vaccination drive reaches younger age groups.

Singapore’s current vaccination registration process already requires people to register for both the first and second doses at the same time, which helps narrow the “intention- action gaps” between the doses. However, past flu vaccination-related studies show that additional nudges, such as personalised reminders, can boost take-up rates and help ensure that people return for subsequent doses. This will be especially useful if the COVID-19 vaccine requires subsequent booster shots or even annual revaccination to keep up its protective efficacy.^21,22

A team at the University of Pennsylvania, led by Professor Katy Milkman, conducted two large field experiments in the US involving tens of thousands of respondents and numerous experimental nudges.

Nudging People to Get Flu Shots

A team at the University of Pennsylvania, led by Professor Katy Milkman, conducted two large field experiments in the US involving tens of thousands of respondents and numerous experimental nudges. They found that sending two reminder texts to patients increased influenza vaccination rates compared to the usual care control. The initial text encouraged patients to ask for a flu jab at their upcoming appointment to protect themselves and their loved ones, while the follow-up text reminded them that a flu vaccine has been reserved for them.¹

In another experiment, Professor Milkman and her team redesigned the reminder mailer by incorporating planning prompts, which help to overcome procrastination, forgetfulness, and potential obstacles. The team was able to increase workplace vaccination rates simply by getting people to write down the date and time that they intend to get their vaccination on the reminder mailer, which also contained information on the free on-site clinics where employees could get the flu shot.^2,3

NOTES

1. Michele W. Berger, “Behavior Change for Good Unveils Effective Strategies to Boost Vaccination Rates”, PennToday, February 18, 2021, accessed April 17, 2021.

2. K. L. Milkman, J. Beshears, J. J. Choi, D. Laibson, and B. C. Madrian, “Using Implementation Intentions Prompts to Enhance Influenza Vaccination Rates”, Proceedings of the National Academy of Sciences, USA 108, no. 26 (2011): 10415–10420.

3. Hopkins Business of Health Initiative, “Special Online Conference on Experimental Insights from Behavioural Economics on Covid-19 (2/19)”, video posted February 23, 2021.

Increasing and sustaining compliance to socially responsible behaviours

In Singapore, nudges could play a role in spaces where the existing social and physical environment may encourage habitual behaviours that compromise safe distancing. These include cafe counters that encourage people to lean over and speak to the servers, or using the phone while waiting in a queue and forgetting to keep a safe distance.²³

Most people do want to follow prevailing health regulations and guidelines,²⁴ but their intentions may not always translate into appropriate action. Nudges can help individuals to close the “intention-action gap”, by redesigning spaces to help people overcome their old habits and prompt them towards socially responsible behaviours.

In addition, the evolving regulations and guidance related to COVID-19 could also lead to people developing risk compensation behaviours over time. For instance, a study found that Americans, after a mandatory mask mandate, spent 11 to 24 fewer minutes at home on average and increased their number of visits to some commercial locations, including “high-risk” ones such as restaurants—despite the rise in COVID-19 cases in much of the US.²⁵

Such behaviours were anticipated by the World Health Organization, which cautioned early in the pandemic that “wearing medical masks can create a false sense of security that can lead to neglecting other essential measures such as hand-washing”.²⁶

This does not mean that governments should not impose a mask mandate.²⁷ Rather, it highlights the possible unintended consequences of such measures. To manage these, policymakers could explore using nudges to remind and persuade the public to keep up with all safe management measures and socially responsible behaviours.

Seeking help for mental health wellbeing

Isolation and stress resulting from lockdowns and quarantine measures, as well as anxiety from catching COVID-19, have soared in many countries. Researchers at Duke-NUS conducted a meta-analysis of 68 studies involving 288,830 participants from 19 countries and found that one in three adults had experienced psychological distress, such as anxiety and depression, related to COVID-19.²⁸

In the UK, a study examining the temporal change in psychological wellbeing of the population in lockdown found an overall increase in mental distress in respondents aged 16 years or older compared with the previous year, even after accounting for the projected upward trend.²⁹ In Singapore, the number of calls made to the Samaritans of Singapore, an organisation providing support to those contemplating suicide, rose by about 30–35% during the Circuit Breaker period compared to the same period in 2019.³⁰

The stigma associated with mental health issues could discourage people from seeking treatment. Nudges can overcome these barriers.

It is important that people seek the help they need, whether from professionals or friends and family, to care for their mental wellbeing, since psychological distress can have long-term consequences. However, the stigma associated with mental health issues, especially among Asians,³¹ could discourage people from seeking treatment.

Nudges can be innovatively integrated into communication channels to overcome these barriers. For instance, some studies suggest that emotional connections to personalities in the mass media, especially in soap operas, can help persuade people to deal with and seek help for “taboo” topics. In South Africa, officials worked with a media company to produce a soap opera with a leading character dealing with gambling and debt issues. Viewers of this soap opera were found to be less likely to engage in gambling and more likely to seek help from the national debt mediation helpline. During focus group discussions, viewers highlighted the emotional connection to the leading character as motivating their behavioural changes.³²

Such studies could be useful references for Singapore’s policymakers, when considering ways to emotionally connect with and nudge members of the public to seek help for mental health issues aggravated by COVID-19 circumstances.

Conclusion

While the rollout of COVID-19 vaccination programmes in Singapore and other countries is cause for hope, it will still be some time before the COVID-19 pandemic is truly put to rest, given its scale, impact and the still uncertain nature of the virus and its rapidly mutating variants that are more infectious and/or resistant to vaccines. Furthermore, while the vaccines do prevent most people from being severely sick with COVID-19, health experts do not discount the possibility that asymptomatic infections in vaccinated individuals could still spread the virus in the community and infect unvaccinated individuals.³³

Hence, we must continue to be vigilant and observe socially responsible behaviours, even after Singapore is past its current spike in community cases, and has vaccinated most of the general population.³⁴

Lockdowns and regulations will continue to play an important role in managing the ongoing pandemic: we will not be able to simply “nudge” the pandemic away. Nevertheless, nudges can play a complementary role in helping policymakers sustain the socially desirable behaviours needed to keep COVID-19 under control in the long run, increase the adoption of and adherence to the vaccination regime, and mitigate other effects of the pandemic.

It is also important to note that people’s behaviours are complex and highly context-dependent. Policymakers must remain agile, relying on evidence to assess the effectiveness of promising nudges in different contexts. Only then might we formulate effective strategies to manage not just the current crisis, but also future pandemics.

ABOUT THE AUTHORS

Do Hoang Van Khanh is Lead Researcher at the Institute of Governance and Policy, Civil Service College. Her research interests include evidence-based policymaking and behavioural economics.

Mervin Loi is Researcher at the Institute of Governance and Policy, Civil Service College. His research interests include evidence-based policymaking and behavioural economics.

NOTES

1. Anja Bauer and Enzo Weber, “COVID-19: How Much Unemployment Was Caused by the Shutdown in Germany?” Applied Economics Letters, (2020), doi: 10.1080/13504851. 2020.1789544.

2. Holly Ellyatt, “UK Unemployment Rose in July despite Lockdown Lifting, with More Job Losses Likely”, CNBC, September 15, 2020, accessed April 17, 2021.

3. Ministry of Trade and Industry, “MTI Narrows 2020 GDP Growth Forecast to ‘-7.0 to -5.0 Per Cent’”, August 11, 2020, accessed April 17, 2021.

4. Elke Van Hoof, “Lockdown Is the World’s Biggest Psychological Experiment—and We Will Pay the Price”, World Economic Forum, April 9, 2020, accessed April 17, 2021.

5. Yi-Ling Liu, “Is Covid-19 Changing Our Relationships?” BBC, June 5, 2020, accessed April 17, 2021.

6. M. Pierce, H. Hope, T. Ford, S. Hatch, M. Hotopf, A. John et al., “Mental Health Before and During the COVID-19 Pandemic: A Longitudinal Probability Sample Survey of the UK Population”, Lancet Psychiatry 7 (2020): 883–892.

7. Simon Denyer, “Coronavirus Is Roaring Back in Parts of Asia, Capitalizing on Pandemic Fatigue”, The Washington Post, November 24, 2020, accessed April 17, 2021.

8. Ibid.

9. Erin Hale, "'Prevention Fatigue' Driving Sudden COVID Surge in Taiwan: Expert", Aljazeera, June 9, 2021, accessed June 9, 2021.

10. Ben Butcher, “Lockdown: Are People Breaking Covid Rules?” BBC, January 13, 2021, accessed April 17, 2021.

11. Linette Lai, “Covid-19 Pandemic Could Last Four or Five Years: Lawrence Wong”, The Straits Times, January 25, 2021, accessed April 17, 2021.

12. Kok Ping Soon, “Nudges: Why, How and What Next?” Ethos, June 30, 2017, accessed April 17, 2021.

13. Behavioural Insights Team, “EAST: Four Simple Ways to Apply Behavioural Insights”, April 11, 2014, accessed April 17, 2021.

14. Gov.sg, “Additional Restrictions under Phase 2 (Heightened Alert) to Minimise Transmission”, May 14, 2021, accessed May 20, 2021.

15. Ministry of Health, "COVID-19 Vaccination", June 8, 2021, accessed June 9, 2021.

16. N. T. Brewer, G. B. Chapman, A. J. Rothman, J. Leask, and A. Kempe, “Increasing Vaccination: Putting Psychological Science into Action”, Psychological Science in the Public Interest 18, no. 3 (April: 2018), pmid:29611455.

17. Mathew Mathews, Syafiq Suhaini, Mike Hou, and Alex Tan, “The COVID-19 Pandemic in Singapore, One Year On: Population Attitudes and Sentiments”, IPS Working Papers No. 40, April 2021, accessed May 24, 2021.

18. Connor Perrett, “Fauci Says a COVID-19 Booster Shot Is a ‘Public Health Decision’ and Not Up to Companies like Pfizer and Moderna”, Business Insider, April 18, 2021, accessed April 19, 2021.

19. Berkeley Lovelace Jr., “Pfizer CEO Says Third Covid Vaccine Dose Likely Needed within 12 Months”, CNBC, April 15, 2021, accessed May 24, 2021.

20. Alex Gyani and Rory Gallagher, “How Can We Support Physical Distancing in the Office?” Behavioural Insights Team, October 13, 2020, accessed April 17, 2021.

21. Ibid.

22. Y. Yan, J. Bayham, A. Richter, et al., “Risk Compensation and Face Mask Mandates during the COVID-19 Pandemic”, Sci Rep 11, no. 3174 (2021).

23. E. Mantzari, G. J. Rubin, and T. M. Marteau, “Is Risk Compensation Threatening Public Health in the Covid-19 Pandemic?” BMJ (2020): 370:m2913, doi:10.1136/bmj.m2913.

24. Ibid.

25. Duke-NUS Medical School, “COVID-19: 1 in 3 Adults Anxious, Depressed”, January 28, 2021, accessed April 18, 2021.

26. See Note 6.

27. Joyce Teo, “Covid-19 Will Have a Long-Tail Effect on Mental Health, Experts Predict”, The Straits Times, August 19, 2020, accessed April 18, 2021.

28. A. C. Krendl and B. A. Pescosolido (2020) found that individuals in Eastern countries who are diagnosed with depression and/ or schizophrenia reported more mental illness stigma—in the areas of prejudice and discriminatory potential—than their Western counterparts. This finding was consistent with prior work.

29. Gunhild Berg and Bilal Husnain Zia, “Harnessing Emotional Connections to Improve Financial Decisions: Evaluating the Impact of Financial Education in Mainstream Media (English)”, Impact Evaluation Series, no. IE 89, policy research working paper, no. WPS 6407, 2013.

30. Joyce Teo, “S’pore Has No Need to Rely on One Covid-19 Vaccine with Several Promising Candidates in the Race”, The Straits Times, November 28, 2020, accessed April 18, 2021.

31. Cheryl Tan, “S’pore Can’t Rely on Herd Immunity, Will Use Covid-19 Vaccines among Other Measures: Gan Kim Yong”, The Straits Times, May 14, 2021, accessed May 24, 2021.

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