Battling health behaviours in Africa: Lessons from Covid-19 for development communication

Thursday, May 21, 2020

Actions of various individuals, social groups and organizations promote or undermine human health. Their knowledge, practices and attitude also contribute to wellbeing, or compromise the quality of life.
From its multifaceted dimensions, coronavirus (Covid-19) raises several behavioural issues which affect its spread, containment, prevention and recovery. Such behaviours play a major role in those who are infected or not infected. They also determine how a society can contain its spread. Many of the behaviours are simple and need to be repeated to become regular habits of life. Some may even become part of the ‘new norm’ post-Covid 19.

A tsunami of information
Information is critical to health behaviour. As the foundation of attitude and action, it is the first step in positive health behaviour. Public health experts agree that awareness or knowledge about a health issue or a disease plays a critical role in health behaviours. This makes awareness creation the key cornerstone of many health education and behaviour change communication, as lack of knowledge undermines people’s ability to take positive health behaviours. However, from empirical evidence and experience, knowledge alone does not translate to action.
Interestingly, there is no shortage of information on the pandemic. With covid-19 ‘information overload’ is an understatement. The pandemic has generated a super-abundance of information, now known as ‘infodemic’. It has created a pandemic with an infodemic, a virus within a virus and a crisis within a crisis. The entire world is suffering from a deluge of information on its origin, prevention, treatment and effect. With the rapidity and creativity involved, it would appear that there is a Misinformation Making Machines (MMM) pumping torrents of messages on the virus to the planet. The tsunami of information and stories has created another disease: ‘Covid-19 Information Indigestion’. We just hope and the impending mutation into ‘Coronavirus Mental Disorder’ is already rearing its head globally.
People just don’t know what to believe, or just believing everything. With new stories, podcasts, articles, experts’ opinions on daily basis, people are even doubting what they knew before. The superabundance of information also creates a public health concern, which according to the World Health Organisation needs to be managed. To say the least, the Covid-19 information avalanche has polluted the information ecosystem, causing doubts on the reality of the pandemic
To address it, we submit that such contested and convoluted information ecosystem should serve as the starting point of health promotion/education and behaviour change communication. A major implication for development communication and health promotion/education is aggressive monitoring of the information environment and responding with appropriate, coordinated and consistent messaging on traditional, non-tradition and digital channels. Similar to crisis communication its speed and creativity should be faster than the misinformation machine. If not we shall be playing catch up.
This should also be supplemented with a sub-campaigns on how to avoid health misinformation and disinformation, which has become critical for Covid-19 and for other health issues. Such a campaign is imperative because of the extensive health misinformation available online and across social media platforms.

Lack of correct information
Despite the dizzying volume of information, the pandemic is characterised by considerable unawareness and lack of correct information. Coronavirus is a novel disease, implying that it was not there before. As a ‘brand new’ and equally’ strange disease’, there are many unknowns that even the foremost researchers and scientists are trying to learn. Thus, as the disease is studied, so would the knowledge about its behaviour expand.
The disease has now spread to all 54 Africa countries. However our informants’ interviews in urban, peri-urban and rural areas, confirm that many people still lack the correct information on the pandemic. From discussion with several segments of the population, and even our own social groups, we have seen extensive ignorance on its origin, its treatment, its prevention and its impact, principally caused by pervasive misinformation and disinformation. Couple with these are the absence of the voices of local research and researchers/sciences in the response to the pandemic across nations.
The main weapon to address unawareness is the dissemination of simple, up-to-date and accurate information. For this group, we need to scale up precise information and messages on the disease. Such information should address their questions, concerns, queries and doubts about the pandemic.
However it is important to bear in mind that such information would have to fight through the current maze of health misinformation and disinformation, hence it must be creative and sharp to break through, and then stick! Such messaging would also consider where each segment of the population is on the ‘knowledge continuum’ for targeted messaging.

A sea of unconvinced population
In some cases people may be aware or have heard of the disease, but do not believe. This is a situation of lack of conviction. For these people, it is not for lack of information, or even ignorance as much as resistance, based on factors such as knowledge, education, belief, experience, misinformation or disinformation.
With covid-19, the sea of unconvinced population is unusually vast. Four months into the pandemic, many people across Nigeria, and other African countries, are not convinced or sceptical about the pandemic. Even with the death of some high profile persons in society and in the Diaspora, some still deny the existence of the disease.
From our interaction with journalists, we hear statements like ‘many people don’t believe the disease’ or ‘people are not convinced’. Findings from key informants suggests that many of such people operate in the realm of deep, not peripheral unbelief, doubt and lack of conviction.
In some communities in Northern Nigeria, most people think coronavirus is ‘a lie’. While in the villages in the South, many think of it as ‘a ruse’. In the South East, people are still having their jolly life. And in many communities in the West, Lagos, Ibadan inclusive, it is business as usual for many who are eager to dare the consequence.
Furthermore, media professionals have been fielding an army of uninformed pundits who parade half-baked opinions and theories on the pandemic. In Nigeria reports from the laboratories is limited to the daily release of number of cases from her centre for disease control. Voices of scientist and researchers are muted while there is hardly media reports detailing the science of the virus, a step in improving the public understanding of the virus. The cumulative effect is what we are seeing – denial of the pandemic and business as usual mentality.
The sources of lack of conviction are multifarious; ranging from the global misinformation campaign, delayed and slow dissemination of correct information in various countries and communities and poor health promotion/education and reporting. Besides, social media has polluted the information eco-system with wild manifold stories, theories and messages on the virus. Many religious leaders have also pushed the conspiracy narrative, and directly or indirectly, pressuring government over the containment strategy. It is also reported some traditional leaders are not convinced and continue their community activities including festivals and local ceremonies. Some go as far as carry out rituals and sacrifices for the intervention of the gods.
The attitude and statements of national leaders may also have contributed to that lack of conviction or indifference from different sectors of the population.
The implication for communication and health promotion/education is how to neutralise the effect of the conspiracy theory and initiate a creative counter-narrative through multiple channels. To be effective, such messaging should be grounded in the context of the narrative but implemented at a large scale for maximum effect. This should not be any of those faint-hearted campaigns that do not achieve results. Rather, it must be a massive health promotion/education and behaviour change intervention with a high level of message dosage and saturation. This is the only way to neutralise disinformation and begin to promote positive health behaviour.

Prevalence of low risk perception
Another major issue to deal with in Covid-19 health behaviour is risk perception. This is defined as the level of an individual’s perception of susceptibility to a threat. In a broad sense, risk perception is determined by several factors and leads to a variety of behaviour. There are also different types of risks. Considered as a whole, risk perception is fundamental to health behaviour.
From key informants interviews and interaction with various individuals, the pandemic typifies low risk perception among segments of the population. This is a feeling that disease is for others and not for them. Some people see it as a strange disease, for the rich, for those who have travelled abroad, or for those living in a particular community or country. Such people do not personalise the risk of the disease; reflected in apathetic response to the containment strategies. No!. We all need to personalise the risk to be able contain the disease.
Addressing this challenge requires intensive risk communication. This involves a robust tracking of risk perception, level and types of risks. It would also entail analysing and integrating such data into messaging and communication interventions. From systematic reviews, interventions that successfully engage and change risks would increase health behaviours.

The challenge of adopting new behaviours and practices
Covid-19 comes with specific preventive and containment behaviours mainly: hand washing with soap under running water, social distancing, wearing of masks, coughing and sneezing into the elbow to avoid spreading infected droplets, and lock down to contain the infection. Illness behaviour for those already infected include self-isolation, testing and reporting themselves to an isolation centre.
The main challenge has been adopting these practices on a large scale. Our qualitative data from different African countries shows various population groups have found it difficult to accept and maintain some of the containment strategies. There has even been human rights perspectives in the mix of resistance to the lockdown of populations
First, some of the preventive strategies such as social distancing and lock down are out of sync with African traditional and economic realities. This makes implementation naturally difficult. Second, illness and sick role behaviour is prone to stigma.
Media reports in Nigeria point to lack of full observance to the preventative and containment strategies in Lagos. The behaviour of some celebrities have contravened health behaviour required under covid 19. And those who are observing it are uncommitted. Social distancing is being delegitimised and compromised. In some cases, it has turned into opportunities for club meeting and ‘old boys’ socializing, or house wives catching up sessions. In markets, public transport, and banks, social distancing is a mirage. It is contrary to African culture.
In Cameroun, churches are still meeting and people don’t understand social distancing. Even after the country had over 2000 cases of the virus, churches in Cameroun were still meeting on Sundays. The Speaker of Parliament, who is now positive refused to self- isolate, and was seen interacting with Parliamentarians in the days leading to being tested positive.
Communities in Malawi, Zambia, Zimbabwe and others question social distancing essence and principles. In South Africa, 73,000 military personnel had to be drafted to enforce some of the containment strategies while in Kenya police had to enforce lockdown with force.
Organizations are critical to promoting health behaviours, because the health of any organization depends on the health of its people. One institution whose behaviour has seems to be undermining the overall health behaviour is the faith institution. While some of the religious leaders are now complying with government directives, many faith leaders have undermined public health behaviour of the population. Some are still holding anointing services with their members in contravention of required health behaviours under covid- 19. Some mosques are holding their services in public without adhering to social distancing guidelines. The pronouncements of some of their leaders also undermine positive health seeking behaviours.
Efforts to promote adherence to health behaviour and practices call for deep root-cause analysis, extensive social mobilization, community sensitization and advocacy with various groups. It also entails understanding the causes of lack of compliance and finding solutions to them. There is need for all sectors to develop sectoral response to COVID-19 in line with WHO international guidelines. However, regardless of the reasons for non-adherence or compliance, it is certain that such behaviour undermines the health and wellbeing of the population. So while positive health behaviour promotes wellbeing, negative behaviour undermines the quality of life.

Some implications for development communication
Covid-19 shows us that health behaviours have significant impact on health outcomes. Simultaneously, it questions the level of preparedness of development communication professionals in engaging with novel and strange health pandemics. It also calls for new ways of social and behaviour change communication.
Covid19 is a new virus. Though it raises known issues in health behaviour, it has to be fought with a different approach. The virus is virulent, so behaviour change strategy must be commensurate. The virus is novel, so must be the tactical approach. The virus is peculiar, so must be our interventions. Evidence is suggesting that coronavirus will be with us for a while. Some practices like face mask and social/physical distancing might continue for a long time.
This is why we call for a completely different kind of development communication, which must be intense, coordinated, and adaptive to assure any semblance of victory.
Finally, as covid-19 is creating a new norm, it behoves development communication professionals and experts to help government, first responders, researchers and scientists, to be thinking and planning ahead on how to promote changes in social norms and desired health behaviour of the future. A creative health communication approach would be critical for the post-covid life.

Prof. Adebayo Fayoyin, Visiting Professor, Department of Mass Communication, Caleb University, Imota Lagos
Akin Jimoh, Executive Director, Development Communication Network, Lagos.