Why might it be hard to encourage physical distancing behaviours in LMIC settings?

Before the COVID-19 pandemic, physical distancing behaviours were not familiar to any culture or country. Humans are social beings - used to being in direct contact with other people in public transit, in the market, in the street, when at work or when meeting our friends and loved ones. Therefore, adopting physical distancing measures will be a significant challenge for all of us.

However physical distancing behaviours may pose an even bigger challenge in low and middle income countries (LMICs). This is because:

  • People in LMICs may be more likely to live in environments that make physical distancing challenging. For example people in LMIC settings are more likely to have more people living in a household with them (making it harder to limit transmission if any one individual gets COVID-19) and are more likely to have intergenerational families (in some settings this may create more of a risk for vulnerable individuals - but not all). Larger proportions of the population may also live in informal settlements in urban areas or camps for displaced populations. These densely populated environments often also have lower rates of water, sanitation and hygiene access, more limited access to health care and face other chronic health challenges. Together, this means that populations living in these settings are more vulnerable to infection and may experience more severe outcomes due to reduced treatment access.

  • People in LMICs are more likely to be adversely affected by the secondary impacts of physical distancing measures. The closure of workplaces, schools and other services has had substantial effects on the global economy. People in LMIC settings are more likely to rely on informal sources of daily income and are therefore more likely to experience losses of income at this time. There may also be fewer formal systems to support people if there are disruptions to local markets and supply chains or disruptions to key health care services.

What specific behaviours should we be promoting in relation to physical distancing?

The primary source for guidance on physical distancing should be national government guidelines as every country has adopted slightly different measures appropriate to their context. Below we describe some of the measures that have been widely adopted. We define each and explain why there are differences in the recommendations between some countries.

  • Stay at a ‘safe distance’: This guideline normally means that if leaving the household you should remain at a safe distance from everyone who lives outside of your household. The WHO currently recommends 1 meter (3 feet) as the minimum distance, whereas CDC states 2 meters (6 feet). Variations in global and national guidelines reflect the fact that our understanding of SARS-CoV-2 is still changing and much of the evidence behind these recommendations is related to other similar pathogens. A recent systematic review indicated that staying 1 meter apart reduced the risk of transmission by 82%. However there is some evidence to suggest that recommendations need to be contextualised as under certain conditions (such as shouting, coughing or exercising) SARS-CoV-2 may travel more than 2 meters. It is the responsibility of governments, organisations and businesses to try to facilitate physical distancing in public settings by adjusting physical environments and using cues to demarcate distancing recommendations.

Source: Physical distancing measures in place at a market in Somalia to help people remain at a ‘safe distance’

  • Avoid gatherings: The WHO has developed this general guidance in relation to mass gatherings. Most countries have set limits on how many people can gather in any one place. Sometimes guidelines are broken down by setting. For example, in many areas some outdoor gatherings are permitted while indoor gatherings need to be smaller or are not permitted at all. Outdoor spaces like parks pose less of a risk for COVID-19 transmission because people are able to maintain a safe distance from each other, and because there are fewer frequently touched surfaces and plenty of airflow which allows the virus to dissipate. Most governments also provide guidance on special events such as concerts, sports events, religious gatherings or special occasions including weddings and funerals. In most settings these types of events are being stopped or are allowed to continue with clear guidance on how they need to be adapted to enable participants to stay safe.

Source: Communication materials developed by Stay Safe Africa to encourage adapted religious practices during Ramadan.

  • Avoid unnecessary travel: In most countries some travel across national and international borders is permitted according to the WHO. However many nations have decided to suspend all flights or substantially reduce flight routes to permit essential travel only. This map provides updated guidance on national restrictions on flights. Unnecessary travel should also be avoided at a local level. This could include encouraging people to shop or visit markets less regularly and to buy products locally where possible. It may also include closing non-essential services (e.g. clothes shops, restaurants or bars) to discourage people from using these at this time and reducing public transport services. In some countries regional borders have been closed or people have been advised not to travel more than a few kilometers from their home. The application of these guidelines is highly context specific and often comes as a trade-off between what is best for reducing transmission and the longer term socio-economic costs.

  • Stay at home if you have COVID-19 symptoms: If a person has COVID-19 symptoms then they should stay at home as should all other members of their household. If symptoms remain mild then all household members should remain home for a period of 14 days. If any member of the household develops serious symptoms then healthcare should be sought (preferably by calling COVID-19 hotlines where these exist). This technical brief from the WHO provides detailed advice on providing safe care to people with mild symptoms at home. Many national governments will have developed contextualised guidance on this as well. This document outlines the adaptations that may need to be considered for providing home care in low and middle income country settings.

  • Avoid physical greetings: All physical contact with people outside your household should be avoided. This includes avoiding shaking hands, hugging or kissing. Many countries have started to promote alternative greeting options such as waving or promoting ‘Namaste’, a greeting often used within South Asia.

Source: Alternative greetings illustrated by Toby Morris

  • Work from home if possible: Many countries have been requesting people to work from home if possible but this is difficult to do for the majority of people living in low and middle income countries (LMICs). Factors that make this recommendation challenging in LMIC settings are that many families will not have access to sufficient IT equipment and internet to allow working from home and that home environments may be smaller on average. Even in high income nations families have struggled to maintain work responsibilities now that they are often also caring for children and facing other social and economic pressures. The additional stress associated with working from home has been documented to have adverse mental health affects. While few LMIC settings are mandating working from home, some have encouraged employers to be flexible at this time so that employees can make adjustments to their work conditions to suit their current situation. However, for those who rely on daily incomes for survival and who work in manual labor professions or the informal sector, working from home is not likely to be a viable option. Instead these individuals need to be supported to maintain physical distancing, safely use masks and practice frequent handwashing. To allow for this, employers should be required to adjust work environments to make them safer and facilitate these behaviours. This may include providing handwashing stations within buildings and at entrances/exits, providing face masks for staff and adjusting work hours or spaces so that fewer people need to be in the same space at the same time.

  • School closure: Even though children are at a lower risk of contracting COVID-19 than adults and are less likely to develop severe illness, children are still susceptible to infection and are potential transmitters of the virus. For this reason many countries have decided to close schools or adjust the way schools are managed to enable physical distancing to be maintained. However, school closure can be detrimental to children’s education and can have social and economic effects on the families of these children. As schools start to reopen, a range of physical distancing measures may need to be put in place. We detail these in this resource.

  • Protect vulnerable individuals: In some countries this is being described as ‘shielding’, ‘self-isolation’ or ‘cocooning’. Basically it means that people who are more vulnerable to severe disease (people who are older or who have pre-existing medical conditions) choose to remain at home with minimal interaction with others within and external to their household. These individuals are typically supported to stay at home by receiving deliveries of food and medicine from family, their community or social support services. In LMIC settings it is likely to be more challenging to apply these principles. This resource outlines a range of options that could be considered by communities or governments in LMIC settings. There are a range of practical challenges with implementing shielding or protective green zones. In particular, it is important that these are introduced in a way that is acceptable within the local context.

Remember that physical distancing still needs to be done in combination with other behaviours like handwashing with soap and mask use.

The above types of physical distancing measures are likely to be introduced and rolled-back in a phased manner. In this document, the WHO provides further details on physical distancing measures and how they can be implemented in an acceptable way. They also provide criteria to help countries and regions decide about when to introduce or roll-back physical distancing measures. This includes applying measures according to the level of local disease transmission and balancing the benefits and risks of public health measures and social measures.

In this resource we have provided broad definitions of physical distancing behaviours. If your organisation is working on physical distancing then it is important that you clearly define each of the target behaviours according to national guidelines and the local context to make sure populations can easily act on recommendations. Follow the process outlined in this resource for further guidance on this.

What practical actions can be used to promote physical distancing in low and middle income countries?

In this section we provide a summary of some general principles of behavior change that can be used for promoting and communicating about physical distancing in low and middle income country (LMIC) settings. Many of the specific examples described in this section are the results of a working session run by The Curve about physical distancing in LMICs. Note that because physical distancing is a new behaviour, none of these ideas have yet been evaluated, but they are based on behavioural theory and community-level innovations. To select which of these actions may be relevant to the settings where you are working, we recommend assessing current behavior among your target population to identify the main barriers and drivers of physical distancing, then review this list and see which actions may enable you to address some of these barriers.

General principles of behavior change for promoting and communicating about physical distancing:

Communicate about transmission: This includes simplified information about how COVID-19 transmits from one person to the next and how physical distancing interrupts transmission by reducing in-person interactions. If people don’t understand transmission, physical distancing and the social compromises associated with it will not make sense for people. Visual communications, such as simple videos or images, can be impactful in communicating how the virus spreads. Try to tailor these to your context so that they depict people who look like your population. The video below from Development Media International is a nice example of how this was done in Burkina Faso.

Source: Development Media International, Burkina Faso

The Mexican government’s social media campaign uses a cartoon superhero to explain and encourage physical distancing in a way that is easy for children to understand.

Be specific and clear about the actions you want people to take: Communications about physical distancing should include information about who should practice physical distancing (target population), when physical distancing should be practiced (setting), and how to keep physical distance (defined behavior). This resource can help guide how to select a target behaviour, population, and setting. Some examples of specific and clear messages to help physical distancing are to avoid all mass gatherings, make essential trips only, and to keep a distance of at least 2 meters from others. These messages also need to be contextualised in a way that people can easily apply them. This website provides some creative examples of how countries in different parts of the world have encouraged people to remember how far 2m apart really is.

Source: Physical distancing messaging from WaterAid India.

Change the physical environment to cue the behaviour: Depending on the context, individuals might forget to apply the advice at relevant moments in their day to day life. Provide timely reminders that prompt them to follow guidelines in critical moments and locations. For example, you can make distancing intuitive by spacing seats apart at health clinics, encouraging people to place jerrycans in a water queue (rather than people queuing themselves) and putting markings on the floor to keep distance at the entrance or inside small shops.

Source: A hospital in India has adapted the waiting hall to enable physical distancing to be maintained.

Source: A bench in Singapore has been divided and marked to encourage physical distancing.

Source: A Water4 WaSH Champion trains community members on physical distancing at water points. She uses simple visual indicators (in this case lines drawn in the dirt) to indicate where people should place their jerrycans and explains that then they can maintain a safe distance and not miss their turn in the queue.

Adapt messages to fit your context by focusing on situations where physical distancing is challenging: To make sure your messages about physical distancing are effective for your target population, they need to be specific to their local realities. When developing communication materials think about the specific circumstances in your context where it will be challenging for people to maintain physical distancing. For example, in Pakistan a TV commercial was used to encourage Pakistanis to stay home and practice physical distancing during Eid.

Source: A television advert created by Khairkhuwah in Pakistan

Similarly, in South Africa some church services are being held in fields to enable physical distancing.

Source: Congregants of the Inhlanhla Yokuphila Apostolic Church In Zion practice physical distancing as they attend a church service in an open field in South Africa.

In Lebanon, some students realised that it would be hard for many people to spend Mother's Day apart, so they arranged a service where roses were delivered to mothers by drones.

Source: Mothers in Lebanon receive roses delivered by a drone for Mother’s day.

In Egypt, when theatres started to reopen, they placed photos of famous Egyptian actors on the seats so that physical distancing would be more acceptable and fun.

Source: El Sawy Culture Wheel Theatre placed photos of famous Egyptians on many of their seats to enable physical distancing.

In other settings, large markets have been decentralized into smaller neighborhood-based markets where people can access basic products closer to home and therefore avoid unnecessary travel and large crowds. Similarly in crisis-affected situations, where hygiene or food distributions are common, organisations have been making adjustments to make sure these processes are safer.

Inspire people to act for the sake of others, not just themselves: Many COVID-19 preventative actions, including physical distancing, require us to make major compromises to our daily lives. While these actions do reduce our own exposure to COVID-19, we often adhere to physical distancing guidelines in order to protect others, particularly those who are most clinically vulnerable. It can be really powerful to link physical distancing with this altruistic idea of doing something with the greater good in mind. For example, the poster below was designed to celebrate the mundane activities of people who stayed home in the UK to protect the lives of others.

Source: Poster designed by Bold White Space.

Distinguish between physical distancing and social confinement:

Many individuals think physical distancing means isolation and confinement. It’s important to communicate that this doesn’t have to be the case and facilitate opportunities to bring people together at this time. For example in the Philippines, online church services have provided new ways for congregations to come together. Other countries have developed COVID-19 mental health support services via phone hotlines, facebook groups, radio, and by training frontline staff on mental health first aid. As noted in this guidance from CDC Africa, it can also help to clearly communicate that physical distancing measures are short term and, where possible, notify the public about proposed dates for things returning to normal. In other settings, people still visit each other but remain outside the house and at a distance.

Celebrate ‘positive deviance’: ‘Positive deviants’ are individuals who manage to correctly adhere to public health advice despite the majority of other people around them not doing so. During an outbreak it can be useful to identify, learn from and celebrate these individuals so that others in their community can be inspired by these relatable role models. It can be useful to conduct video or audio interviews with ‘positive deviants’ where they share their tips for how to practice physical distancing in a feasible way. See this webinar for information about applying positive deviance to COVID-19 response. It can also be useful to highlight normal, everyday reactions to physical distancing behaviours. For example this video captures the frank experiences of people who are physical distancing in the UK, discussing what they are missing, how they are coping and why they are motivated to continue despite large personal sacrifices. Similarly, MTV Shuga has set up a ‘Alone Together’ channel where characters discuss their every-day experiences of COVID-19 and challenge misconceptions about the virus.

Utilise trusted community leaders and networks: Community leaders and other influential individuals can be key to encouraging new physical distancing behaviours and are likely to be able help in normalising these practices. Community networks can help response actors understand the local context, explain local innovations and coping mechanisms, disseminate information and provide guidance on acceptable project implementation. Start by mapping out existing community networks, identifying trusted individuals and understanding how they currently work and could be strengthened. In many countries Mutual Aid and savings groups have been set up at a local level to support vulnerable people who are self-isolating or shielding.

Make physical distancing part of the ‘new normal’: It is important that physical distancing behaviours are normalised. To do this it is useful to think both about the delivery channel you are working through and the content of the messages. Some delivery channels, like mass media can be used to show physical distancing behaviours in action and therefore help to position them as normative. It’s also possible to use these formats to show people doing the wrong behaviours, or facing barriers to adhering to prevention behaviours. In this series of short videos from Zambia, they do just that and then show incorrect behaviours being corrected by others in the community or overcome through community level action.

Provide a range of alternative actions: It is useful to think of physical distancing measures as a spectrum ranging from the ideal set of practices to less ideal but more feasible options. This is important to factor into national or regional planning since there will be a lot of variation in the individual experiences of the COVID-19 pandemic (e.g. in terms of clinical vulnerability, socio-economic impact and personal circumstances). For example, many governments are recommending that older people and those with pre-existing conditions self-isolate in their households. However, it is common that these individuals will live within larger households where others are not at high risk and where these individuals need to continue to go to work and undertake some necessary travel. Furthermore, vulnerable individuals may not always reside in houses which are large enough to allow them to be isolated in a dedicated space. In such circumstances it may be necessary to provide guidance on the ideal self-isolating procedure (e.g. where vulnerable individuals have their own house and where relatives drop off necessary food and goods to them to minimise their contact), but also provide guidance on demarcating ‘safe’ areas of the household, encouraging frequent cleaning, handwashing with soap, mask use and planning which external activities can be reduced.

Editors' note

Author: Eva Manzano and Sam Gil (CAWST)

Reviewed by: Max Friedrich, Miriam Harter, Ben Tidwell.
Last update: 16.09.2020

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