Penn Nursing

America the Policy Lab

With public health best practices butting up against social norms during the pandemic, experts are determined to develop policies that incorporate scientifically sound precautions while balancing the likelihood of behavior change in our communities.

On July 24, 2020, 284,191 new coronavirus cases were reported worldwide. Of those, 74,360 were in the United States. Governors, mayors, and school districts across the country were grappling with decisions about reopening schools. Politicians and health experts continued the debate over mandates aimed at stopping the spread of the disease, such as business closures, social distancing, and mask wearing.

On that day, we spoke with Cristina Bicchieri, PHD, director of Penn’s Behavioral Ethics Lab, and Alison Buttenheim, PHD, MBA—the Patricia Bleznak Silverstein and the Howard A. Silverstein Term Endowed Professorship in Global Women’s Health at Penn Nursing and a public health researcher and behavioral epidemiologist—about policy’s role in the pandemic and impact on social norms. In terms of state and local health departments innovating and experimenting amid the crisis, Buttenheim noted, “We have a little policy lab going on right now in the U.S.” We discussed effective health messaging, the credibility of influencers, enforcement, and more.

Would a nationwide COVID-19 public health policy in the U.S. be more appropriate, or is letting each state or city set their policy more helpful when it comes to preventing spread?

ALISON BUTTENHEIM: The epidemic looks very different in different parts of the country right now. However, it would be helpful to have really clear national guidelines from the CDC that said, “When community transmission looks like X in your city, we recommend these guidelines. When transmission is down to Y, then the masking guidelines or the distancing guidelines should be this.” It would help to have that type of gating criteria. Policy solutions are useful because we remove burdensome decision-making from individuals. We don’t want individuals having to make zillions of decisions every day.

CRISTINA BICCHIERI: I think it’s very difficult in the U.S. because states are quite free to decide how much and when to use certain means of protection. I think the government should have been much clearer giving guidelines to all states.

Do public health experts have a rule of thumb on how long to get from a new mandate to social norm?

BUTTENHEIM: It’s so different, behavior to behavior.

How do you effectively communicate policy?

BUTTENHEIM: Repeated, clear, consistent, simple messaging. One of the reasons that’s hard in the current pandemic is that our evidence is evolving really fast. In July we had completely different masking guidance from what we did earlier in the year. That’s very distressing for people, cognitively.

“One of the reasons [repeated, clear, consistent, simple messaging] is hard in the current pandemic is that our evidence is evolving really fast.”

BICCHIERI: And if there is a change, explain why there is a change. Another thing that I think is very important is sending different types of messages to different demographics. What I’ve seen in recent research is that, and it’s quite obvious, younger people have different needs and behaviors than older people. Not only do they have other needs, but their perception of risk is very different. Young generations tend to be more optimistic, probably also because the common message, at least initially, has been that mostly old people and those with preexisting diseases tend to get sick.

What about getting so-called influencers to spread policy messages?

BICCHIERI: It’s absolutely true that using influencers is very important for a range of public health policies. I am interested in the influence that trendsetters may have, and the conditions under which they succeed, because they may not. It’s very important that an influencer’s message is credible to the people they address. You have to be very, very careful about that.

BUTTENHEIM: If Dr. Fauci is wearing his Washington Nationals mask, that’s great for folks who already look to him as a trusted source. It’s a little more complicated with the Surgeon General, who made some really nice attempts to promote masking. But if you don’t support the Trump administration, his credibility drops.

In educating people, is it better to take baby steps or aim for sweeping change?

BICCHIERI: At some point in Italy, there was a message that you could visit with some people, but not everybody. People started asking, “Can I see my family? Can I see my cousins? Can I see my close friends?” I’m sure there are a lot of situations where small steps lead you to behave in a better way overall, but with COVID, incremental is a big risk. And the risk is, “Okay, so I should wear the mask in this particular environment, but maybe I may not wear the mask here.” People often try to find similarities among situations, where they are allowed not to wear the mask. I would not be incremental. I would be very clear where the mask has to be worn, without tinkering very much with that.

BUTTENHEIM: Would it be great if everybody wore their mask all the time? Yes. But that’s not realistic. So whether it’s a policy or, more likely a public health campaign, you ask: Which folks are having the most trouble with this? How do we get people who are not masking at all to mask a little bit? For folks who were already doing pretty well, how do we get them to increase the proportion of time they’re masking outside, or convince them to be a “mask champion” in their social network?

How should policymakers follow up on measures being put in place during COVID-19?

BICCHIERI: It’s very important to do longitudinal studies because when we do randomized control trials, and afterwards we recommend a particular policy, it’s not clear at that time whether the policy will keep being successful or if it is sustainable. Sometimes behavior changes for a while but then there is slippage, and at that point we’ll want to know why there was slippage, what went wrong.

What types of enforcement are helpful?

BICCHIERI: In Italy, it wasn’t left up to the individual to decide when and how long they could leave home, and behavior was closely monitored. You would download a form from the Internet to explain why you were going out—let’s say, “I’m going to the supermarket”—but otherwise you would be severely fined. In a situation where contagions are increasing, should the government introduce fines? I think so, in some very specific and controllable cases, keeping in mind that monitoring is costly. The policy was quite successful.

BUTTENHEIM: I’d say that the surveillance and enforcement costs of fining people for not masking probably exceeds its benefits. Also it could serve to highlight the fact that people aren’t masking.

BUTTENHEIM: Seat belt mandates! A few years ago, I got in my car just to repark across the street due to parking rules. As I started the car, I decided I didn’t need to put my seat belt on just to repark. I did the U-turn, reparked, opened the door to get out of the car, and — oof! I had actually put my seat belt on. Other people have reported similar stories. Seat belt laws and norms have made it such an automatic behavior for most of us that even when I decided not to do it, my habit overrode that decision.

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