Mariken Leurs¹, Jet Sanders¹, Caroline Costongs², Alison Maassen², Gabriella Sutton²

¹National Institute for Public Health and the Environment in the Netherlands (RIVM)

²EuroHealthNet

Introduction

Individual-level behaviour drives the majority of risk factors that lead to disease. In fact, approximately 60% of the disease burden in Europe can be correlated with seven behaviour-induced risk factors. These include tobacco use, harmful alcohol consumption, high blood pressure, high cholesterol levels, overweight, low fruit and vegetable intake, and lack of physical activity (WHO Regional Office for Europe, n.d.).  With these risk factors on the rise, a report by the World Health Organization (WHO) on good health and healthy behaviour labelled this trend the “epidemic of the 21st century”  (WHO Regional Office for Europe, n.d.).

The impact of behaviour-related determinants of morbidity and mortality gives more impetus to focus on methods that facilitate behaviour change to improve health outcomes and reduce the overall disease burden. The methods by which this can be achieved consist of understanding and tracking behaviour and developing and testing behavioural interventions. Along with insights derived from studying other determinants of health behaviour (culture, socio-economic context, environmental influences), behavioural insights fill an essential knowledge gap about the barriers and drivers to achieving optimal health outcomes (WHO Regional Office in Europe, 2021). Understanding barriers and drivers of health behaviours and systematically using the insights this generates to encourage better health outcomes are key to supporting the development of effective and equitable health policies (WHO Regional Office for Europe, 2020).

Within the context of COVID-19, WHO has emphasised the importance of integrating behavioural evidence in the fight against the pandemic. Behavioural insights are considered an essential tool in e.g. understanding the degree of compliance with measures imposed during a health crisis, explaining vaccination uptake, or evaluating and developing novel behavioural policy and communication strategies, as seen throughout the ongoing pandemic. Such insights are subsequently translated into behavioural solutions or solution aids. In line with this priority, the WHO Regional Office for Europe launched a new Behavioural and Cultural Insights flagship in 2020 – as a part of the European Programme of Work (EPW) 2020-2025 – with the aim of supporting Member States in gaining insights into the underlying barriers to and drivers of health, through an evidence-based and multidisciplinary approach (WHO Regional Office for Europe, 2020).

Against this background, this article examines the role of public health agencies in gathering behavioural insights during the COVID-19 crisis and how these insights can contribute holistically to pandemic management. The article sheds light on the behavioural insights work produced by the National Institute for Public Health and the Environment (RIVM) of the Netherlands, and its role as a public health agency in providing coordinated behavioural scientific support to policy-makers and government during the crisis.

The link between COVID-19 and behavioural science

The COVID-19 pandemic has seen the introduction of various behavioural measures designed to reduce the spread of SARS-CoV-2, such as avoiding handshakes, wearing face masks, working from home where possible, limiting in-person social contact, and maintaining physical distance (EuroHealthNet Magazine, 2020).

Compliance with COVID-19 measures is shaped by common behavioural determinants, such as people’s perception of the effectiveness of the measures (whether the measure will help to prevent infection), their risk perception, and their social or physical environment. Examples of environmental factors include social or practical support from employers to work from home; floor markings in public spaces or shopping areas to indicate 1.5m distances; nearby COVID-19 testing facilities; or financial aid for those with income loss. Other determinants of compliance include people’s mental, physical and social health, and timeliness of measures (e.g. when infection rates are higher, support for more stringent measures is higher, too).

The role of RIVM in research on behavioural insights as part of COVID-19 pandemic management

Since the start of the pandemic in Europe (spring 2020), several large-scale behavioural studies have been conducted by the RIVM, in collaboration with the Netherlands Municipal Public Health Services and Medical Assistance in Accidents and Disasters (GGD-GHOR) and the Municipal Public Health Services (GGDs), supported by an Academic Advisory Board and topic specific teams of experts in various social and behavioural sciences. The studies aim to map behavioural patterns and determinants to understand compliance with COVID-19 measures over the course of the pandemic. The data are collected through two separate surveys (a large-scale cohort survey and a nationally representative cross-sectional survey), focus groups and periodic interviews. RIVM also maintains a database of relevant international literature.

Both surveys consist of multiple waves. The first wave of the cohort survey was conducted in April 2020. With three-to-six-week intervals the 17^th wave of data collection took place between 24 and 28 November 2021. Each wave consists of 40,000-50,000 adult respondents (>16 years). Respondents in the cohort study are slightly more often female, more often with a higher level of education, and a somewhat higher average age than the average population in the Netherlands. Younger age groups and people who are not vaccinated are also underrepresented. For this reason, the cohort survey was complemented by a short cross-sectional survey carried out every three weeks (from October 2020 onwards) with a representative sample of around 5,000 participants, spread evenly over 25 designated “safety-regions”, each assigned a risk level depending on the number of confirmed cases and hospitalisations. A map of these safety regions can be accessed here. RIVM also conducted regular interviews and focus groups to improve the understanding of key outcomes of the cohort-study, to reach specific segments of the population, and to inform future surveys.

Through the RIVM’s dedicated Corona behavioural unit, these data were aggregated to provide actionable evidence for policy-makers and communication campaigns. It is worth noting that with no previous infrastructure in place, the Corona behavioural unit was rapidly put together and up and running within the first weeks of the pandemic, starting off with a staff of 45 experts from behavioural and communication sciences, psychology, sociology and anthropology (National Institute for Public Health and the Environment, 2021a) (National Institute for Public Health and the Environment, 2021b) (EuroHealthNet Magazine, 2020) (Leurs, 2021).

From the results obtained, it was evident that RIVM could distinguish between compliance of three types of prevention measures:

-          those targeting hygiene-related behaviours,

-          those targeting mobility and distancing, and

-          those focused on testing and isolation.

Whereas support for and compliance with hygiene-related advice has been high and largely stable over time, the measures which limit mobility and social lives have been more variable. When infection rates were higher, there was more support for distancing and mobility restrictions; but when infection rates decreased, support for restrictions also decreased, mobility increased, and social distancing decreased. As for the third cluster of behaviours, compliance with testing and isolation measures increased during the first six months of the pandemic and was largely stable after that.  

One example of the use of behavioural insights in this context relates to the introduction of rapid flow testing. This resulted in increased use of these tests when individuals had symptoms and reduced PCR-testing. Following the observation of this trend, the unit completed a vignette study to test for adaptation of the communication and availability of rapid flow tests at home. Amongst other things, the advice which followed resulted in an update to the government’s advice on testing procedures for COVID-19 when an individual has symptoms, to include rapid flow testing as a valid option (see here for more information).

The most important opportunities for improving adherence to prevention measures were identified, for example in improved communication and modifications of the physical environment to facilitate behaviour (e.g. organise testing nearby, one-way walkways). Throughout 2021, the Corona behavioural unit did extensive work on vaccination uptake and has been advising communication strategists on the campaigns to support vaccination acceptance since January 2021 (National Institute for Public Health and the Environment, 2021).

Supporting the fight against COVID-19 through behavioural insights –key challenges and lessons learned in the Netherlands

Overall, the data captured by the RIVM-driven surveys, focus groups and interviews demonstrate that countries have the potential to learn from the crisis and utilise behavioural insights as tools in the decision-making process. Furthermore, countries can capitalise on these experiences by integrating insights and embedding behavioural science into new organisational set-ups intended to withstand future crises.

National-level reflections on the RIVM Corona behavioural unit highlight the limited infrastructure dedicated to behavioural studies in existence before the pandemic hit. While this rapid crisis-based set-up fortunately had enough capacity to start functioning immediately, the process of building such an infrastructure was resource-intensive. This process provided an opportunity to identify areas for improvement. For instance, data was aggregated and interpreted better when specialists were brought into the process at an earlier stage. Similarly, as most resources were dedicated to the operation of the unit, limited efforts could be channelled toward exchanging knowledge and best practices with similar units in other countries. Notwithstanding, the supporting role of the WHO Regional Office for Europe, EuroHealthNet and the International Association of National Public Health Institutes (IANPHI) has been useful in facilitating some of this exchange and learning.

Conclusions

Despite the outlined opportunities for improving the quality and impact of behavioural research in pandemic times, the RIVM Corona behavioural unit developed a substantial research portfolio, garnered the capacity of behavioural science expertise in the Netherlands, and managed to make substantive contributions to government policy and communication over the past 21 months. Moreover, it can be observed that embedding behavioural capacity allowed for closer collaboration on necessary COVID-19 public health operations and activities, such as national testing and vaccination coverage.

Looking ahead, given the strength of RIVM’s focus on behavioural insights, there is great potential for the behavioural unit to further impact decisions made at regional and national governmental fora, to incorporate the behavioural lens, and promote better compliance to health policies across the board. In addition, the learnings taken from the rapid embedding of behavioural science during the COVID-19 pandemic in the Netherlands may serve as a proof of concept and a blueprint for other countries who may benefit from a similar approach.

References

EuroHealthNet Magazine. (2020). Applying behavioural science in the battle against the coronavirus.   https://eurohealthnet-magazine.eu/applying-behavioural-science-in-the-battle-against-the-coronavirus/

Leurs M. (2021). Experiences of the Corona Behavior Unit in the Netherlands. EuroHealthNet General Council Meeting of June 2021.

National Institute for Public Health and the Environment. (2021). Results of research into rules of conduct and well-being. https://www.rivm.nl/gedragsonderzoek/maatregelen-welbevinden

National Institute for Public Health and the Environment. (2021a). Social well-being is improving, compliance with coronavirus measures remains important. https://www.rivm.nl/en/news/social-well-being-is-improving-compliance-with-coronavirus-measures-remains-important

National Institute for Public Health and the Environment. (2021b). Applying behavioural science to COVID-19. https://www.rivm.nl/en/coronavirus-covid-19/research/behaviour

Sanders JG, Spruijt P, van Dijk M, Elberse J, Lambooij MS, Kroese FM, de Bruin M. (2021). Understanding a national increase in COVID-19 vaccination intention, the Netherlands, November 2020–March 2021. Eurosurveillance 26(36), 2100792.

WHO Regional Office for Europe. (2020). WHO Behavioural and Cultural Insights flagship – tailoring health policies. Copenhagen, Denmark.   https://www.euro.who.int/__data/assets/pdf_file/0009/462744/BehaviouralCulturalInsights-flagship-eng.pdf

WHO Regional Office for Europe. (n.d.). Good health starts with good behaviour. Copenhagen, Denmark.   https://www.euro.who.int/__data/assets/pdf_file/0005/140666/CorpBrochure_Good_health.pdf

WHO Regional Office in Europe. (2021). About Behavioural and cultural insights for health. Copenhagen, Denmark. https://www.euro.who.int/en/health-topics/health-determinants/behavioural-and-cultural-insights-for-health/about-behavioural-and-cultural-insights-for-health