– Lynne Rippenaar-Moses. Above: The lockdown forces millions of people to spend prolonged periods of time together in close proximity to one another.

As the COVID-19 infection rate accelerates at an alarming pace in South Africa, an article authored by two academics at Stellenbosch University (SU) warns that adherence to lockdown rules in conditions where citizens live without secure and paid work may be difficult without addressing the country’s particular structural barriers to behavioural change.

“In South Africa, unlike in the United States where the infection rate is climbing at an exponential rate due to political and ideological reasons, we are facing specific structural barriers that are particular to this country and will hinder individual behavioural change,” explains Prof Ashraf Kagee, a psychologist and Distinguished Professor of Psychology at SU, who is one of the co-authors of the research article.

The article was co-authored with Dr Bronwyné Jo’sean Coetzee, also from the Psychology Department at SU.

“While our President has managed the situation well and the implementation of the lockdown has given our health systems time to get ready for the influx of COVID-19 infected patients and the large number of people who now require treatment, lockdowns require people to stay home and only leave their homes to purchase essentials such as groceries and medication,” says Kagee.

“As we know, in low- and middle-income countries, many of which have large proportions of the population living in precarity, lockdown forces millions of people to spend prolonged periods of time together in close proximity to one another and with limited resources. In many ways, efforts to contain the spread of COVID-19 in densely populated communities with limited access to food, water and sanitation may seem counter-intuitive and be quite difficult under conditions of precarity,” add Kagee and Coetzee.

These circumstances, explain Kagee and Coetzee, have again highlighted the fact that while COVID-19 may not discriminate against anyone in terms of vulnerability to infection, it does discriminate based on socio-economic status.

“Isolation assumes that everyone has access to personal space and has the ability to continue with paid work from home. In many low- and middle-income countries like South Africa, work is often of a physical nature and cannot be done remotely, as may be the case with many white collar jobs that have been integrated into the digital economy. Thus jobs in the informal sector such as street vending, mini-bus taxi driving, hawking, artisanship, domestic helping, and casual work in small businesses, which are common in South Africa, are likely to be lost. To this extent Covid-19 does indeed discriminate by socio-economic status as it exacerbates social and economic inequality that occurs consequential to lock down.”

Like many other experts in various sectors in South Africa, Kagee and Coetzee echo the same sentiment – managing the crisis in this country will require a multi-disciplinary team of experts such as policy makers, economists, psychologists, and medical professionals to work together to find realistic solutions that are specific to South Africa’s challenges. They believe that there is also a unique role for psychologists and mental health specialists to play to ensure behavioural change and adherence to regulations.

Coetzee and Kagee are however cognisant of the fact that “behavioural change is difficult and complex” under even the best of circumstances. However, by utilising what is known as the Theoretical Domains Framework, which incorporates a range of theories on behaviour change which was developed by health psychologists and theorists and implementation researchers in the context of other health challenges, they have identified possible solutions to local challenges. The framework uses factors such as knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory, attention and decision processes, the environmental context and resources, social influences, emotions and behavioural regulation to measure behaviour change.

“Based on this framework, we have made some recommendations that may ameliorate the severity of the lockdown in low- and middle-income countries like South Africa. The first is for governments in these countries to take their populations into their confidence and ensure proper access to information concerning the spread of the pandemic. Access to such information needs to be readily and easily accessible, simple and clear and updated frequently with accuracy and care,” Kagee and Coetzee explain.

“It entails placing an emphasis on the responsibilities of citizens to take care of their health and that of their compatriots, rather than on the punitive consequences associated with the violation of lockdown conditions. Relatedly, the rationale for lockdown rules need to be communicated in a transparent way to citizens by governments. This is one of the things that I have been very critical about. We have ministers that come up with suggestions and guidelines that do not make sense to the South African population, however, to ensure adherence government needs to take its citizens in its confidence and share the information on which they base their decisions,” adds Kagee.

Kagee and Coetzee also advise that “authoritarian and military approaches to ensuring adherence should be kept to a minimum”.

Other recommendations made by Kagee and Coetzee include:

  • That information about COVID-19 and rules and regulations are made available and tailored to children and younger people and that parents are provided with tools and resources that are age-appropriate and child-friendly. The tailoring of messages for the youth is of particular importance as past experiences, such as changing health risk behaviours amongst the youth when it comes to practising safe sex, was difficult to implement amongst the youth. This is due to a sense amongst many youth that they may be invincible and have nothing to lose and thus immune to the coronavirus and its consequences.
  • That internet access is made widely available by making data as affordable as possible, or even free, to ensure the free flow of information to all citizens: Free or affordable data will allow more people to access information, including where to seek help for COVID-19-related symptoms, mental health conditions, help for those affected by gender-based violence, and access to learning materials for school and university learners.
  • Criminalising fake news and misinformation to minimise panic and incorrect health practices.
  • Scaling up access to e-banking to allow more citizens to receive welfare relief in countries where national budgets permit this.
  • NGOs and local charities are roped in to provide food relief to impoverished communities as well as providing water tanks and sanitising equipment provided by government.
  • Engaging traditional healers in countries where they have influence, to encourage people to adhere to lockdown regulations and safety behaviours.

Adherence is not only hard for those living in overcrowded areas in South Africa, as has been proven through the public sharing of video and photographs of individuals living in better economic conditions breaking the rules. This, says Kagee, is partially due to the fact that individuals have an inherent “need to be with other people and engage”.

“There is a lot of anxiety amongst ordinary people who are worried about whether they will have access to health care when they get sick or what will happen should they end up in hospital and have to be placed on a ventilator, which brings up concerns about death. People with pre-existing mental health conditions are struggling even more, while gender-based violence has also increased.”

“The reality is that this virus is not going to go away soon and there is no way of predicting when things will stabilise, which means that we need to find solutions to mitigate risk under these circumstances. A couple of decades ago, nobody wore seatbelts and people smoked in cinemas, but that changed over the years with the implementation of regulations which brought about behaviour change. It shows that we can shift social norms and are able to do so once again with this pandemic to at least ameliorate the severity of the lockdown.”