Persuasion and Public Health: Evidence from an Experiment with Religious Leaders during COVID-19 in Pakistan

"[P]ublic health campaigns should go beyond the use of mass messaging; the strategy should be supplemented with some form of collaboration with focal community leaders at the grassroots level."

Religious institutions and leaders may play a key role in promoting voluntary compliance with public health measures in the context of a health emergency. As trusted sources of information (or misinformation), they can have a substantial influence over the economic, social, and health behaviours of adherents, particularly among marginalised communities. With an eye to investigating how communication from religious leaders may influence pro-social public health behaviour, this randomised controlled trial (RCT) in Pakistan measured the impact of one-on-one engagement with local religious leadership on the compliance of protocols (e.g., mask wearing) at their mosque. It aims to improve the implementation and communication of the 20-point plan that was agreed between the government and religious clergy to keep mosques open while containing the spread of COVID-19.

Pakistan is a setting with a low degree of trust in secular authorities and their public health guidance: In the 2012 World Values Survey, 60% of Pakistanis reported feeling little or no confidence in the government; on the other hand, about 80% of respondents in that same survey agree that it is an essential characteristic of democracy for religious authorities to interpret the laws. In this largely Muslim country, congregational prayers, including obligatory Friday prayers, present significant risks for transmission of COVID-19 if not managed properly.

The study was conducted over a 3-week period before Eidul Azha in July 2020. At that time, policymakers feared a spike in the number of infections, similar to the rise in COVID-19 cases observed after Eidul Fitr in May 2020. Participants in the study were 819 religious community leaders (imams) from 19 districts across Punjab, covering both urban and rural areas. The respondents were randomly divided into three groups, of which two received an interactive persuasive telephone call (one featuring secular persuasion alone, and one featuring secular + religious persuasion). Both types of calls included basic information on COVID-19 asymptomatic spread and how it can occur at the mosque (e.g., when people stand close together or use the communal wash tap). Both calls also included details on the directives issued by the government. However, the secular + religious call also included appeal to religious authority using a combination of ahadees, fatwas from renowned religious scholars, and examples of measures taken by other Muslim countries to prevent spread of COVID-19.

The phone calls then segued into an appeal to the respondent's influential role as an imam and his responsibility - a prosocial appeal - to protect his community (especially the elderly and vulnerable) by disseminating the COVID-19 prevention guidelines to his colleagues and congregants through sermons and mosque loudspeaker announcements. Notably, the messaging on the phone calls was interactive, involving frequent elicitation of the respondents' reactions and agreement, as well as asking them to commit to action.

The researchers followed up with the imams 2 days before Eidul Azha to gauge compliance with COVID-19 prevention measures at their mosque by noting things such as whether or not the respondent advised wearing a mask, bringing one's own prayer mat, or performing ablution at home. Overall, the treatment increased the index of COVID-19 compliance instructions by 18% (7 percentage points). For example, those imams who received the persuasion scripts were 25% more likely to advise their congregants to wear a mask to prayers. Key points:

• This result held despite the fact that imams who received the persuasion scripts and those that did not possessed similar levels of awareness regarding basic COVID-19 facts.
• Furthermore, 70% of the imams in the study had received some form of messaging regarding the spread of COVID-19 via government announcements, TV, and newspapers, but only 26% of them had advised their congregants to wear a mask prior to the study.
• Moreover, the engagement was equally effective with or without explicitly religious content in the scripts.
• Thus, the key mechanism that made the engagement successful was neither educating the imams on the basic facts about COVID-19 nor framing the health guidelines in secular or religious directives. Rather, it worked by connecting this knowledge with their power to persuade as community leaders and their responsibility towards their community.

By focusing on one-on-one engagement with focal community leaders, this study is in line with previous interventions like Pakistan's polio vaccination drive, which disseminates knowledge and engages at the community level. Thus, the results from the study can provide insights for strategies used by other public health campaigns to engage the public and build trust, such as the COVID-19 vaccine. As of March 2021, only 2.2% of the 8 million senior citizens in the country had registered for inoculation, while a nationwide poll in January 2021 revealed that over 40% of Pakistanis were unlikely to get themselves vaccinated. In light of such potential hesitancy, the researchers stress that the government needs to formulate an effective communication strategy in order to impress upon the public the importance of remaining cautious and getting vaccinated. This is where partnering with communal leaders, including religious leaders, could be beneficial for the dissemination of health authorities' messaging to foster more effective COVID-19 prevention.

Click here to listen to a podcast on the study.