Most public health programs focus on educating the public, but this doesn’t always lead to behavioural change. In order to encourage change, this information should focus on short, clear messaging about what people need to do on the spot (call to action).

The number of people breaking COVID-19 self-isolation rules was successfully reduced with a simple A5 multilingual postcard and a short script for clinicians (teach back). People did not need the comprehensive information usually provided in health brochures. This research shows the power of ‘less is more’ in helping people to comply.

This post draws on my team’s previously published results.

Summary

• This study stopped people leaving self-isolation before they got a negative COVID-19 test result
• The study was undertaken in a highly multicultural region in Western Sydney.
• Behavioural science helped people comply with the rules. Patients were given a small, multilingual flyer, plus, clinicians followed a simple script (‘teach back’). This included a simple message:

Thanks for getting tested. You need to do 2 things:
1) Go straight home. Don’t stop off along the way.
2. Self-isolate.

• The postcard focused patients’ attention on important details by using icons and colour. The postcard provided advice for overwhelmed people
• The proportion of people leaving home isolation was reduced by 29% (‘self-isolation breaches’)
• The intervention is now used across New South Wales

Background

In late 2020, many people were confused about how to correctly self-isolate after getting a COVID-19 test.

We worked to stop people leaving self-isolation before getting a negative result.

Our multidisciplinary team includes sociologists, economists, psychologists, and statisticians. We work on Gadigal land, Sydney, in the state of New South Wales, which has the highest proportion of overseas-born people. We carried out our research in Western Sydney, which has four of the top 10 biggest non-English-speaking local government areas in the country (see page 45). Three of us co-led the project — we are all migrants from non-English countries who speak different languages. We have lived experience on how diverse communities interact with health services. I have expertise in racial inclusion and have led previous studies on culturally relevant services for vulnerable clients. These factors led us to focus on multicultural service delivery.

What We Did

 In 2020, we worked with NSW Health, SydPath and Western Sydney Local Health District to run a trial to identify and remove behavioural barriers to correct self-isolation.

We conducted fieldwork in Western Sydney to understand the behavioural barriers impacting on correct self-isolation behaviour. This research showed that people panicked once they got tested and would leave isolation to get essential items or to pick up children from school. We also found that testing clinics were providing a range of different leaflets with dense information.

We worked with clinicians to co-design and test a behavioural intervention using

• A small (A5) multilingual handout, double-sided
• ‘Teach-back’ instructions about self-isolation.

Teach-back is an effective way to improve health comprehension. Clinicians follow a script. They then ask patients to repeat key instructions. They also allow time for questions and explanation.

We tracked results via a short survey, which was delivered via SMS.

How We Did It

Our intervention and survey were given in English and in the other three biggest languages in Western Sydney, which have the lowest level of English-language proficiency: Chinese, Arabic and Korean. 

Our study included 76,000 people in Western Sydney. We analysed 8,000 valid survey responses.

The behaviourally informed handout provided simple, but targeted, written information at the point of testing: a clear call to action, practical steps to overcome barriers to self-isolation, assurance about the 24-hour time waiting for results, and multilingual instructions.

The behavioural science techniques embedded in our handout include:

• Simplification: Breaking down complex and unfamiliar tasks into easy steps increases compliance. The handout told people the two things they need to do immediately after leaving the testing clinic: 1) Go straight home. Don’t stop off along the way. 2) Self-isolate. The instructions were provided in Easy English.
• Salience: People are more likely to pay attention to details that stimulate their senses (such as attractive colours), and which focus attention on important details. Our handout reminded people they’ll get results within 24 hours, and they should stay home even if they don’t feel sick. Graphics of the key messages aid understanding.
• Scarcity mindset: People who are busy or overwhelmed have limited ability to take in new information and make optimal choices. We can help busy people who feel unprepared for self-isolation by offering suggestions to major behavioural barriers. 
• Timeliness: People are more likely to take action if they receive clear directions at an optimum time. Rather than overwhelming customers with detail, we focused on essential information they need at time of testing: how to best self-isolate at home. Additional information about testing and self-isolation from the business-as-usual leaflets were accessible via a QR code. Each language had its own QR code, that led customers to a translated webpage.
• Make it easy: Asking for translated materials is sometimes a barrier. Our double-sided multilingual handout included four languages in one place. This meant customers weren’t forced to request additional help, and staff didn’t spend time trying to find the right materials for those who need it most.

A sample of our behavioural handout is included below.

‘Teach-back’ is an effective way for health professionals to check whether customers are confident in following directions when they leave a healthcare setting. We provided clinic staff with standardised script on self-isolation that mirrors the messages in the handout. Customers were then asked to repeat back what they need to do to correctly self-isolate. Clinic staff also had a checklist, to ensure they listen for key information.

Teach-back ensures clinic staff don’t assume customers’ understanding and ability to action directions (that is, their health literacy), and provides opportunity to ask questions and clarify self-isolation issues.  

The teach-back script draws on the following behavioural principles:

• Simplification: Clarifying messages strengthens compliance. The script clarifies the meaning of self-isolation and reinforces the call to action from the behavioural handout.
• Temporal discounting: People tend to discount future benefits and consequences. The script emphasises that 24 hours is a short wait for peace of mind on test results.
• Error management: People are more likely to make mistakes in stressful working conditions. Checklists present complex information clearly and concisely, ensuring important details are not missed. Our checklist ensures clinic staff can double check the customer has understood the key messages on self-isolation.

What We Found

We reduced self-isolation breaches by 29%.

Only 11% of people used the QR code to access more information on self-isolation on the NSW Health webpages. Most people visited the English page but spent little time reading these resources (there was a 70% bounce rate, meaning people left within seconds of opening the page).

Our results suggest that QR codes may be useful for instrumental purposes (e.g. COVID Safe check in), but less impactful in delivering health education. Further testing is required on the efficacy of QR codes for delivering complex health information. It seems likely that the public requires less information and responds well to simplified directions that clarify what they need to know on the spot.

Our research has now been scaled across New South Wales. Scaling is when a successful intervention is expanded to a broader population. Our message has been incorporated into a singular handout given to all patients tested in public clinics (below).

We also collaborated with the Department of Health to create a new online training module and video to help clinicians learn about the flyer and teach-back script.

How Social Science Helped

Our project shows how

• Applied sociology adds value to multidisciplinary teams
• Diverse scientists make a real difference to public health

Notes

Read our previously published results.