Young women in Pakistan using mobile phones.

Few health issues in living memory have posed as many global challenges as the Covid pandemic.

As the virus swept across continents, different governments with very different health systems and public attitudes battled to slow the spread of the virus and protect stretched medical services.

The responses ranged from extreme measures – such as curfews and lockdowns – to more innovative ‘nudges’ aimed encouraging people to modify their behaviour accordingly.

One such innovation was pioneered in Pakistan, where ringtone messages were used to educate people about coronavirus and take steps to contain the virus.

The messages were created by the Ministry of Health in Pakistan, working in partnership with the United Nations Development Programme, to combat the misleading information and confusion that followed the country’s first confirmed case of Covid-19 in February 2019.

Experts needed to find a novel approach, because less than 10 per cent the country’s population listened to radio and television was an expensive medium to share public health information.

However, 90 per cent of people had a mobile phone. So the team, including Warwick Business School behavioural scientist Dr Umar Taj, developed a series of ringtone messages that played down the line whenever someone made a call and was waiting for the recipient to answer.

Speaking to mark World Health Day (on 7th April) Dr Taj, said: “Crises like Covid-19 demand innovative thinking and governments need to look outside their usual toolkit to create impact.

“Evidence showed that using mobile phones was the most effective option, but we couldn’t use text messages due to the low literacy rates in Pakistan.

“So we came up with the idea of replacing ringtones with a recorded health message. The idea was simple – every time you call someone, you hear the ringtone message.”

The team analysed the most effective messages to encourage people to make key behavioural changes, such as hand washing, wearing masks, and socially distancing.

They then developed three ringtone messages, which each version improving on the last.

The results were impressive. More than 113 million people heard the messages and after doing so, they were:

• 71 per cent more likely to identify fatigue as a symptom of coronavirus.

• 53 per cent more likely to identify breathing difficulty as a symptom.

• 31 per cent more likely to perceive the serious threat COVID-19 posed to them or their family.

• 45 per cent more likely to use hand sanitiser and 43 per cent more likely to wear a mask.

Dr Taj, who grew up in Islamabad before moving to England to study at Warwick, said: “We knew the ringtone messages needed to empower people to stay safe, rather than spreading fear, and contain the most important points in the first 15 seconds as most calls are answered within that time.

“This has been one of the most successful behavioural change interventions in response to Covid in Pakistan. We managed to reach almost the whole adult population, with barely any cost and robust positive outcomes.

“The ringtones can also be adopted fairly easily by other governments around the world.”

It is just one of the projects Dr Taj has worked on that aims to improve international health outcomes, having created Pakistan’s  first behavioural science lab with market research firm Gallup.

“I have always been more interested in applying behavioural science to the real world, than in writing another research paper,” he said.

For his Phd, he decided to use gamification to try to address the longstanding problem of people failing to finish their course of antibiotics, increasing the risk of microbial resistance to them.

He said: “We thought, what if we create an avatar of a person that shows them they are still sick, with germs running around their body to show bacteria is still there.”

“We created a computer game, where the person playing is the patient, so we could test our ideas.

“Another idea we tested in the game was what happens if the pill keeps you sick for longer so it takes longer for symptoms to go away and they last the course of the antibiotics.

“It was very interesting and the game provided a very safe environment to test these ideas. I have advised a few pharma companies on antibiotic adherence with the results since.”

Dr Taj also founded Nudgeathon to give his students chance to apply what they had learned to tackle a social challenge and see it have an impact.

He was inspired by the concept of Hackathons, which see numerous computer programmers and software designers tackle a single problem, usually over 24 hours.

Using a similar format, he assembles teams of behavioural scientists and stakeholders who use ‘nudges’ – relatively low cost changes that influence behaviour – to tackle social issues.

Nudgeathons are growing in popularity, taking place in Sweden, China, Australia, Mexico, Pakistan and Kuwait. Universities and organisations across the world have asked him to set up similar events.

Dr Taj said: “Nudgeathons are typically on complex or wicked problems, so there is no easy solution, and there will be multiple stakeholders involved, so you have to co-create solutions. All the different

“By coming together we create ownership of the problem from everybody as well. It’s a very new way of building stakeholder engagement and co-creating solutions for complex policy challenges.”

One such problem was the UNAIDS goal to end the HIV/AIDS epidemic as a public health threat by 2030. That requires action to optimise the uptake of HIV testing and effective prevention technologies, with a particular focus on how to target hard to reach subpopulations.

As part of the  Nudgeathon, behavioural scientists and other stakeholders identified a series to address, including how to improve PrEP medication uptake and regular HIV testing for at-risk individuals, where the costs are immediate, but the benefits are felt much later.

They devised a number of promising ‘nudges’, including improving HIV/STI testing and encouraging PrEP use among overseas-born males engaging in same sex relationships in Australia.