Since 2009, members of the Empatika team have carried out immersion-based and participatory research in Indonesia as well as in nine other countries. During immersions, we live with households and share in their everyday lives by experiencing it ourselves. This approach provides insights into people’s everyday lives and allows us to consider what people say and what they do, within their own reality. While we adopt a holistic view that engages with all aspects of people’s lives, many of our studies have been commissioned by those specifically interested in topics related to health, hygiene and nutrition. Here we present insights from our work in these areas relevant to COVID-19, as well as the implications for policies and programmes.
Why do some health behaviour change programmes work and others do not? By living with families in over 75 rural and urban locations in Indonesia, we have gathered insights that can be used to address public health challenges. These details are essential to tailoring messages and approaches to address the drivers of key health behaviours, like hand washing, breast feeding, or health seeking practices.
For example, in our research people frequently say that they know that they are supposed to wash their hands before eating. But from our experience living with them, we see that people are instead much more likely to wash hands after eating to remove food and smells. People have internalised the message related to hand washing which is often learned by rote, but this has not translated into practice.
The COVID-19 pandemic is likely to hit low income countries – and specifically the poorest people within these countries – the hardest. Governments, UN Agencies and development programmes need to react both quickly and effectively to prevent the worst from happening. Global public health programmes have taught us that the best health policies and programmes are those which are evidence-based. This has already proven imperative during this crisis, as people are being asked to dramatically alter their daily lives in order to keep themselves and those around them safe.
In a recent article, the Centre for Global Development argued this point: 'Some of the best interventions we have, such as handwashing, are under emphasized. The World Health Organization includes good respiratory hygiene as part of its standard guidance on how to reduce respiratory virus transmission. In places where people don’t cover their mouth or nose with a tissue or elbow when coughing or sneezing, efforts to promote these practices have been piloted successfully in schools in Bangladesh and may be a good investment to scale quickly.'
At Empatika we know that, for example, government messaging through WhatsApp groups and on Facebook is not sufficient to promote behaviour change, even for practices as simple as washing hands. There is ample evidence from our immersion research that such messages are often ignored and that people’s understanding of health, hygiene and cleanliness is needed to support change.
Social distancing and travel restrictions limit the options available to collect up-to-date information on how people are responding to the pandemic. However, Empatika’s extensive experiential insights gathered over more than six years may help inform responsive interventions. This includes a network of families across Indonesia with whom we have lived and can communicate with remotely to assess behaviour change and community responses to the crisis. We hope to be able to share these insights and their implications to support policy makers and programmes to design the most effective interventions and forms of support possible to help communities get through the pandemic.
In this slum area where our researchers lived, some people still need to pay for the water they use for washing or cooking (IDR 3,000-5,000 for taking water in buckets in 2017), which could make regular hand washing unlikely especially in the context of decreased incomes. As many social scientists have noted, ‘social distancing’ is also very challenging in informal settlements like these.
'Those [posters] are designed for city people'
90% of SD [primary] students say they wash their hands regularly. However, our immersion findings show that students washing their hands before eating food and/or after going to the toilet almost never happens.
'This [cough with phlegm] is because they are kids - it will disappear when they are older'
1. Daily washing is important for personal and religious reasons but is often viewed as removing visible dirt, stickiness, sweat and smells - NOT as a means to remove germs or pathogens. It is also often about smelling nice. Usually this bathing takes place after returning home or at the end of the day, allowing for a whole day of potential contamination.
2. Children learn about germs at school but do not apply this knowledge to how they could avoid infections. The emphasis on rote learning and memorising for school tests without practical demonstrations, experiments and learning by doing exacerbates the disconnect between knowing and doing.
3. Since pathogen pathways are generally not understood, people do not make a connection between touching others or sneezing, coughing or spitting near others and illness. Social distancing and hand washing would therefore not make sense without ensuring these connections are fully understood.
4. Minor fevers, coughs and other symptoms typical of COVID-19 are considered normal and are usually attributed to changing seasons, spirits and, in children, associated with normal ‘growing up’. No special measures to prevent these ‘normal’ phenomena or to seek medical advice are usually taken, which means that those with mild symptoms go undetected and unaddressed.
5. Rural families often indicate that illnesses are urban in nature: a function of pollution, overcrowding, ‘lazy lifestyles’, and processed foods. Rural people frequently self-define as strong and fit because of fresh air, active work/lifestyles, and homegrown food and may therefore not consider themselves likely to get COVID-19.
6. People often associate the appearance of a new illness with outside and external factors. This means that outsiders and non-Indonesians are likely to be identified as carriers without recognising that, in fact, anyone can transmit the virus.
7. Women across Indonesia typically make all of the day-to-day household financial decisions. Decisions to purchase soap, detergent, sanitizer, water (where it needs to be purchased) and other items such as face masks will be made by women.
8. When mothers are sick some stop breastfeeding in the belief that what has caused her sickness (e.g. spicy foods, bad spirits) will be passed on to the baby. UNICEF has indicated that COVID-19 is not passed through breastmilk and that breastmilk provides the best nutrition and immunity to other infections.
9. Being seen to conform to social norms is particularly important in Indonesian communities and gossip is often spread about those who don’t conform. These norms may be useful in enforcing social distancing and other precautions.
10. Most people own mobile phones (including smartphones) and use social media, though primarily for entertainment and maintaining social contact. Most people do not pay special attention to government messages or proactively connect to official sources of information using phones, especially if this involves phone charges or requires them to make a special effort to connect to a stronger signal.
11. People we have lived with across Indonesia often complain that information they do access through social media is unreliable, ‘fake’ and misleading and find it hard to distinguish between legitimate information sites and others.
Diarrhoea was blamed on spirits or spicy food in West Java while in East Nusa Tenggara it was blamed on vaccinations and the ‘chemicals in packaged food’. Across locations nobody made any connection between cleanliness and good health.
‘They throw this idea of stunting at us - we do not understand where this illness came to us as we eat fish - why all of a sudden do they say we have this illness?’
1. The virus that causes COVID-19 needs to be visualised as ‘unseen or hidden dirt’ / ‘unpleasantness’ that can be everywhere. Hands touch more things in the course of a day than other parts of the body so this ‘unseen dirt’ will be most prevalent on the hands.
2. This ‘unseen dirt’ can be transferred by and between everyone - nobody is an exception to this.
3. Hand washing should be prioritised over all other washing. Instead of showering each day, water (especially where in limited supply) should be prioritised for handwashing – with a target for all of washing hands at least five times per day with soap for 20 seconds.
4. Soap and/or detergent need to become non-negotiable household consumable priorities, especially going forward as food shortages and price hikes could increase as a result of the pandemic. As women make household financial decisions, this message needs to be strongly communicated to them.
5. Since social distancing will be challenging to adhere to, especially in urban slums and low cost housing areas, the potential seriousness of what are usually regarded as ‘normal coughs and fever’ needs to be communicated. Those showing these symptoms, even though they would normally shrug then off, need to be isolated.
6. Don’t expect too much of messages conveyed through phones. People often ignore/delete these.
7. Small hand washing stations (low cost ‘tippy taps’, for example) could be installed in front of any place where people often go or pass by, e.g. the village office, posyandu, market, kiosks. Since conforming to social norms is important, public demonstration through these provisions of the key importance of regular hand washing is likely to have traction.
8. To understand the need for washing hands and not touching one’s face, eyes, mouth, babies with unwashed hands, etc., the idea of chopping chillies (which everyone can relate to) could be used as a proxy to explain the ‘unseen virus’. You would not rub your eyes; feed your baby; put your hands on your face, etc. after chopping chillies. Ouch!
A baby chick walks around near a baby and food in a researcher's household in Central Kalimantan. In our studies we have seen that it is common for people to eat and prep food in common spaces including floors, and that animals are often able to roam freely including while food is being eaten or prepared.
‘Children here are very strong. None of them wore a mask last year, whereas I myself was wearing one’