Public health practitioners at the heart of behaviorally-informed evolution of public health practice

I recently was discussing the state of behavioral science and its mainstreaming into public health practice. Much of public health service delivery and prevention efforts all depend on promoting health behaviors, adherence to health guidelines and acceptance and demand for health services. Health systems could get much more effective at achieving health and well-being of populations if our practices, systems and structures incorporated participatory methods and behaviorally-informed frameworks to tailor health programs and services to people and put people at the center of health service delivery.

In infodemic management, we ultimately look at the intersection of how the information and designed environment contribute to barriers and enablers of health behaviors, adherence to health guidance and recommended behaviors. The infodemic has manifested itself in the rapid spread of questions, concerns and misinformation that can affect population attitudes and behavior harmful to health—from promoting stigma and discrediting science, to promoting alternative, non-recommended treatment and cures to politicizing public health programs and eroding trust in healthcare personnel and health system.?

Infodemic managers work at the intersection of the information ecosystem, individual cognitive, psychological and health attributes, and the health system and society. I have come to believe that the only way that the public health practice will fully support trust-building with individuals and communities, is if the whole of the health system consistently and responsively fills the needs of people, especially at-risk and vulnerable populations.

But that means that all our approaches, computational, legal, behavioral, communication, digital, etc, must be demystified and made available in such simple forms that non-specialists can take them up in their own everyday public health and health care work.

So I was asked recently about my general thinking on how we can make behavioral science more integrated globally into health systems and public health. Here's my key points:

1. Behavioral sciences are not commonly found in Ministries of Health or Institutes of Public Health. Investment in behavioral science and implementation research is dominant in high-income countries which means that many interventions developed are not applicable in low and middle-income settings. Even in high-income countries, behavior science work in public health is costly, slow and difficult to link to improving health outcomes.
2. Most of behavioral work started and was done through behavioral economics. But it’s much harder to change health behaviors than economic/household behaviors. There’s been a proliferation of nudge units, mostly in high-income countries, but the problem is that nudging can only change behaviors by a few percentage points and requires a strong primary health system because it assumes that health care access is not an issue.
3. Since we know that in LMICs, access to health care is an issue, any behavioral interventions in LMICs are bound to fail without addressing health service delivery and access issues at the same time or even first. Unfortunately, much of behavioral work in experimentation does not consider building systems or putting the center of work inside health programs. For example, low vaccine demand in a low-income country may be related to access or hesitancy, and behavioral interventions that only address vaccine intent don’t actually shorten the distance between the caregiver and health facility or ensure that vaccines are in stock.
4. And the above is the situation in routine setting. In emergencies, socio-behavioral science is funded to address an acute problem but this is not routinized into routine health service delivery. We saw this during ebola, and also now during COVID-19.
5. And then there is also the challenge of the fact that behavioral science frameworks are not sufficient to alone improve public health practice. Namely, the range of behaviors that we consider individuals and populations should enact in the context of health goes beyond just performing a health behavior. There are many kinds of harm that can be caused, stigma, violence against health workers, vaccine refusal or use of substances like ivermectin or hydroxychloroquine that lead to overdoses and deaths. This is why infodemic management embraces behavioral approaches but amalgamates it with the broader context.

The only way we will mainstream innovation and new skills into the public health practice is if we integrate it into job aids and practices of everyone in the health system. As much as they used to be nascent practices years ago, nowadays no one questions the need for all health workers and public health practitioners to have basic digital literacy skills, understanding of equity, evidence generation and interpretation, and similar.

I see infodemic management skills and behavioral approaches in a similar way.

So what should be done to introduce behavioral science and methods into public helth practice systemically?

• Consider inclusion of wider sets of socio-behavioral data into health and programmatic analysis to improve policies and strategies, technical cooperation with countries, and ultimately improving population health outcomes.
• Introduce behavioral frameworks into guidelines for public health intervention design
• Introduce implementation research approaches and behavioral frameworks into the evaluation of innovations, experiments and programmes for scaling up programmes.
• Foster innovation in generation of new data sources that are less costly and more targeted and relevant to populations of focus and vulnerable groups

And how could we do this?

• Mainstream human-centered design approaches in intervention development, implementation and testing.
• This is a matter of culture change - Develop a toolkit for human-centered design and behaviorally informed tools for HCD work, for rapid prototyping and encouraging staff in health authorities to be more inclusive of community members in the development and evaluation of health programmes.
• And, we need to think more broadly than KAP surveys. They tell us the what but not the why. For example, KAP surveys are great at describing the problem of the infodemic but do not help diagnose and inform interventions.
• This is why we need more types of behavioral assessment tools that can be used by nonbehavioral scientists across health authorities.
• Here's an example from infodemic management: instead of assuming countries will hire specialist behavioral scientists to be placed across the health system, we need to provide guidelines and tools that enable nonspecialists to use behavioral approaches and frameworks in their practice. Countries do not have the structures or the funding to establish units within the strained health systems, so why don't we set the knowledge free and mainstream it into the public health practice?
• Lastly, often forgotten, but really important, I think the development of behavioral assessment tools must take into account the lens of gender in assessing the appropriateness and acceptability of health interventions. It is key to ensure service delivery and programs meet the needs or populations and are effective.

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