Ten Considerations for Effectively Managing the COVID-19 Transition

"Continued cultural adjustment of the response strategy fosters spaces for listening to the voices of diverse communities during the development of behavioural strategies and the creation of support processes for sustaining behaviours..."

With no vaccine or effective treatment for COVID-19 available to date, governments around the world have implemented measures to manage the transmission of the virus, such as social and physical distancing measures (SPDM). Due to the high social, psychological, and economic cost of many of these measures, countries and smaller jurisdictions are entering a phase of transition or de-escalation of these measures. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. The transition phase should also be informed by real-time data according to which governmental responses should be updated. This report proposes 10 considerations to support these principles.

First, however, the paper explores various unwanted scenarios that could be associated with a poorly timed and/or badly managed transition. For example:

• A lack of perceived risk (e.g., due to declining cases or psychological adjustment to the new situation) could cause decreased adherence to measures such as SPDM. These reactions may be exacerbated by messages that question the appropriateness of government pandemic measures, which can increase distrust among segments of the population.
• Specific population groups - e.g., people who lack social support structures or people with lower literacy - may be challenged by or lack the capability to continue adhering to restrictions and recommendations.
• As response strategies are adjusted, debates in the political and public spheres related to unresolved dilemmas or the appropriateness of the implemented measures may increase. People will need to navigate these adjustments and the lack of predictability, as well as complex and ambiguous messages and possibly competing demands from the social and cultural environment regarding social interaction.
• Some people, such as individuals who are at higher risk of severe illness (and their families) may be advised to continue strict compliance with restrictions, which may expose them to new forms of stigma, blame, or discrimination as societal expectations shift.

To avoid these potential unwanted scenarios, this group of authors calls for evidence-based planning and consideration of the perspectives and engagement of populations, as well as experts from the social and behavioural sciences and medical humanities. They propose these 10 considerations for governments, which do not imply a temporal sequence and are interrelated, just as listening to communities, engaging with them, and informing them are interlinked:

1. Implement a phased approach to a "new normal" - e.g., "The COVID-19 transition process involves defining and communicating specific phases in advance, while also accounting for the uncertainty of the outbreak evolution; preparing people for planned adjustments to the response strategy; and transparently communicating what is known, what is not known and the criteria applied when making decisions."
2. Balance individual rights with the social good - e.g., "[T]he continued adjustment of the response strategy...should be maximally respectful of rights and the foundational interest of human dignity....Empirical evidence can inform this decision-making by enabling authorities to understand norms and values, ensure the acceptability of implemented and planned measures with respect to both individual and societal gains, and detect shifts in acceptance or barriers to measures..."
3. Prioritise people at highest risk of negative consequences - e.g., "The greatest negative impact of COVID-19 is felt amongst people who experience disadvantage, especially poor and underserved groups....Working closely with unions, worker collectives and organisations that serve people at the margins can help ensure that the transition is structural."
4. Provide special support for healthcare workers and care staff - e.g., "Access to workplace or home-based webinars...and the development of structured information delivery during handovers and in-service meetings can support this important group. This support could be combined with financial and symbolic rewards and public recognition..."
5. Build, strengthen, and maintain trust - e.g., "A strong sense of public trust is critical for harnessing public cooperation and achieving the high rates of behaviour adherence necessary for pandemic management." Some suggestions for bolstering this:
   • Transparently communicate what is known, what is not known, and what efforts are being taken to learn more.
   • Ensure that scientific advice to governments is not subject to political or government influence.
   • Foster stakeholder coordination to facilitate consistency and reinforcement of messages.
   • Obtain the support of individuals or groups who enjoy high levels of trust (e.g., religious leaders, former politicians, and public figures from the arts, culture, and sports) to communicate important messages or to reach more population groups in culturally and linguistically diverse populations.
   • Put in place robust democratic infrastructures for community voices and pathways for these voices to be translated into decision-making.
   • Provide open access to relevant information in culturally sensitive language(s).
   • Highlight examples of community engagement to demonstrate that the population is being heard and that their views are being considered by decision-makers.
   • Use surveys to understand how shifts in trust may be related to new events or new restrictions, and respond accordingly.
6. Enlist existing social norms and foster healthy new norms - e.g., "[I]ncreasing people's sense of social empathy towards those at highest risk could be helpful...for promoting prosocial actions, such as reducing crowds and avoiding the hoarding of essential supplies (for example, medical masks). Regular surveys and culturally sensitive studies can be employed to understand social norms and expectations related to COVID-19, detect shifts in these norms and possible new emerging issues (for example, stigma, misperceptions and conspiracy theories) and feed into planning and communicating the most socially acceptable measures."
7. Increase resilience and self-efficacy - e.g.,:
   • "Recommendations for strengthening resilience include accepting the inevitable (i.e., that the pandemic has already had a substantial impact on our societies, which may be alleviated but is not likely to end in the near future); focusing on positive gains (for example, being able to see some friends again even if we cannot attend large parties); drawing attention to progress (for example, identifying strategies that have been working); measuring and attending to people’s day-to-day emotional states and well-being and improvements in public health; taking responsibility (for example, acting where possible); understanding our limitations (making changes that are possible and accepting what is not changeable); reversing negative thoughts (focusing on learning rather than on mistakes); and knowing our strengths (highlighting past successes as individuals and communities and strengthening people’s sense of self-efficacy). In some settings, where basic needs are being met and appropriate resources are available, resilience training can be conducted using apps, online programs or large-scale media campaigns..."
   • "Explaining what should be done (for example, regular handwashing with water and soap) and the reasons for doing it...can promote response efficacy....Making change as easy as possible so that people understand the actions they should take to protect themselves and providing feedback on these actions can increase self-efficacy....Strengthening self-efficacy and response efficacy in a manner that reaches people with low health literacy can empower people to control and take ownership of their actions and generate adherence to protective measures."
8. Use clear and positive language - e.g., "[W]hile a language of crisis, panic and war can increase risk awareness...it can also cause anxiety, incite selfish or competitive reactions and undermine people's sense of collective support and care....[T]he aim should be to highlight the gains that can be made from engaging in target behaviours and activate the internal moral compass that renders personal rewards less important than benefits to others..."
9. Anticipate and manage misinformation - e.g., "Prebunking and debunking approaches (i.e., inoculating people against misinformation before it spreads and correcting misinformation after it appears) will also be needed if and when a COVID-19 vaccine becomes available, as misinformation about this topic is likely to be disseminated."
10. Engage with media outlets - e.g., "A combined approach that targets legacy platforms, audience-specific and local outlets and social media may be the most efficient....The following key messages may be employed: this is an unprecedented situation; there may be changes to the strategy as we learn more; this is a solvable situation; and greater restrictions may become necessary again in the event of a second or third wave. Journalists and the media can support the framing of the transition phase as an all-of-society approach and responsibly perform their important role by avoiding actions such as feeding confusion and blame and reporting inconsistent messages, controversies, rumours, misinformation and speculation..."

The authors stress that these considerations need to be adapted to individual contexts. Thus, the process should be informed by a situation analysis and by current evidence from behavioural, social, and cultural sciences applicable to the specific context (examples are provided in Table 1 of the paper), and it should be supported by engagement with communities.

In conclusion: "Understanding how the pandemic and the restrictions imposed are affecting people's everyday lives, their social and mental health, and their motivation and intentions to follow recommended practices is critical for the sustained success of the pandemic response during the transition...and will be a valuable source for ensuring our preparedness for future pandemics."

Full list of authors, with institutional affiliations: Katrine Bach Habersaat (WHO Regional Office for Europe, Insights Unit); Cornelia Betsch (Center for Empirical Research in Economics and Behavioral Sciences, Media and Communication Science, University of Erfurt); Margie Danchin (The University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital); Cass R. Sunstein (Harvard University, Harvard Law School); Robert Böhm (Department of Psychology, Department of Economics, and Copenhagen Center for Social Data Science (SODAS), University of Copenhagen); Armin Falk (University of Bonn and Institute on Behavior and Inequality, or BRIQ); Noel T. Brewer (Department of Health Behavior, Gillings School of Global Public Health, and Lineberger Comprehensive Cancer Center, University of North Carolina); Saad B. Omer (Yale Institute for Global Health, Department of Internal Medicine (Infectious Diseases), Yale School of Medicine, Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale School of Nursing); Martha Scherzer (WHO Regional Office for Europe, Insights Unit); Sunita Sah (Cambridge Judge Business School, Cambridge University); Edward F. Fischer (Department of Anthropology, Vanderbilt University); Andrea E. Scheel (WHO Regional Office for Europe, Insights Unit); Daisy Fancourt (Department of Behavioural Science and Health, University College London); Shinobu Kitayama (Department of Psychology, University of Michigan); Eve Dubé (Département d'Anthropologie, Université Laval); Julie Leask (Faculty of Medicine and Health, University of Sydney); Mohan Dutta (Center for Culture-Centered Approach to Research and Evaluation (CARE), Massey University); Noni E. MacDonald (Department of Paediatrics, Dalhousie University); Anna Temkina (Department of Sociology, European University of St. Petersburg); Andreas Lieberoth (Danish School of Education, Interacting Minds Center, Aarhus University); Mark Jackson (Wellcome Centre for Cultures and Environments of Health and WHO Collaborating Centre on Culture and Health, University of Exeter); Stephan Lewandowsky (School of Psychological Science, University of Bristol; and University of Western Australia); Holly Seale (School of Public Health and Community Medicine, University of New South Wales); Nils Fietje (WHO Regional Office for Europe, Insights Unit); Philipp Schmid (Department of Psychology, University of Erfurt); Michele Gelfand (Department of Psychology, University of Maryland); Lars Korn (Center for Empirical Research in Economics and Behavioral Sciences, Media and Communication Science, University of Erfurt); Sarah Eitze (Center for Empirical Research in Economics and Behavioral Sciences, Media and Communication Science, University of Erfurt); Lisa Felgendreff (Center for Empirical Research in Economics and Behavioral Sciences, Media and Communication Science, University of Erfurt); Philipp Sprengholz (Center for Empirical Research in Economics and Behavioral Sciences, Media and Communication Science, University of Erfurt); Cristiana Salvi (WHO Regional Office for Europe, Insights Unit); Robb Butler (WHO Regional Office for Europe, Insights Unit)