(Part One of Two)
By Ellen Lambert and Emily Hayes
Pandemics like the current one with COVID-19 are caused and contained by how people behave: each person’s chance of contracting the virus depends not only on their own behaviour, but also on the behaviour of their fellow citizens.
There are a number of things we can all do to slow the spread of infection, reduce strain on the NHS, support our wellbeing and the wellbeing of others.
The authors of this blog (Ellen and Emily) are two graduate psychologists with a keen interest in health psychology and public policy. We graduated together from the Department of Behavioural Science and Health at University College London a few years ago. Emily currently works at the Centre for Behaviour Change at UCL and Ellen is a member of the Stress, Psychiatry and Immunology Lab, the team who bring you InSPIre the Mind!
We have chosen to write this blog together because we think it’s important to consider how scientific theory and evidence can help us understand and change behaviour in these testing times.
In part one of a two part series, we define a key model of behaviour change and we reflect on what we have learned about human behaviour from past pandemics. Part two will be published next week and will review messages from government and public health authorities in response to the Coronavirus both in the UK and internationally.
Capability is our physical and psychological ability to enact a behaviour.
For example, our psychological capability is increased when we receive clear and simple guidance and instruction, like learning how, when, how long and where to hand wash properly.
Repeatedly practising a behaviour helps us to perform it effectively and self-imposed action plans and if-then rules can also help to increase our capability. For example, if we leave the house, we will wash our hands immediately on our return.
Opportunity relates to our social and physical environment.
We can try to remove social barriers that might get in the way of us changing our behaviour. For example, we can ask others to remind us not to touch our face when they catch us in the act, and we can normalise new behaviours by explaining them aloud.
Before the lockdown, we were in a café when a man arrived for a job interview at the opposite table. He politely announced that he would not shake the interviewer’s hand due to the current situation. This prevented any awkwardness, and everyone understood why the usual social custom had been avoided.
You can apply the same idea during essential trips outside, if you feel unsure that others will observe the 2-meter rule. A signal of sticking an arm out has become a visual “nudge” to remind others to keep to the recommended distance.
To improve the physical environment to promote health behaviours, we can ensure we have resources to hand, like a sensible amount (e.g., without stockpiling) of soap, tissues and sanitiser, and we can use prompts to remind us to enact a behaviour.
This excellent website creates hand washing posters with the song lyrics of your choice — great for if you need a break from singing happy birthday!
Motivation can involve conscious intentions and evaluations (reflective motivation), and habits and emotions (automatic motivation). Choosing to support the NHS and avoiding breaking the law/having to pay fines are examples of reflective evaluations that drive our motivation to stay indoors.
We have both also created an action plan for exercise, where every day at 5pm, Ellen practices yoga and Emily does a fitness video for half an hour, both of us trying to stick to routine and so doing this in the same room each time.
Repeating behaviours, especially when done at the same time and in the same place, can eventually help us to form lasting habits — thus increasing automatic motivation.
Authorities can influence automatic motivation by drawing on emotions such as empathy and solidarity. For example, by highlighting how our behaviour can benefit others in our community — especially those more vulnerable — and by using language that centres around “we” and “us” rather than “I” or “you”.
Public health and government messages can support us by:
letting us know what is expected of us to reduce the spread of COVID-19 in a clear and succinct format,
explaining why this is the case, and
stating clearly what support is available.
Experiencing positive emotions, such as enjoyment, can make new behaviours easier to maintain. Video calling apps like Zoom and Houseparty have soared in popularity and allow us to substitute actual meet ups with virtual ones.
They can provide us with much needed social contact and enjoyment whilst staying at home. They helped us to plan this blog and have been used to host quizzes, movie nights and soon, Emily’s 30th birthday (not quite the party that was originally planned…).
We can also apply the COM-B model to help us to perform behaviours that can support our wellbeing during the lockdown.
For example, after listening to a presentation by Dr. Ben Gardner at the ‘health and wellbeing during the Covid-19 pandemic’ public webinar series hosted by the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, we were both inspired to try to reduce the amount of time we spent sitting at home.
Emily created a standing-desk (from books and an ironing board), whilst Ellen filled up small glasses of water rather than pint glasses — both of which provided opportunities to reduce our sedentary behaviour.
Most importantly, we must try to be kind to ourselves. Changing and maintaining new behaviour is not easy at the best of times and slip ups happen.
We must be worried enough to take action but not so worried that we start to panic (read here for a great guide on dealing with worry during the pandemic).
Diving into the past: examples of human behaviour during past epidemics
Now that we’re clear on the fundamentals of the COM-B model, let’s take a look back at some epidemics that occurred in the past and how humans behaved, keeping in mind the three key components of the model…
Capability
Regarding “capability”, the importance of clear communication from trustworthy institutions, and the damage that disinformation can cause, were clearly exhibited during the outbreak of the Ebola virus disease in the Democratic Republic of the Congo a few years ago.
During this time, internet trolls were spreading fake news across Facebook and WhatsApp that accused the USA of bringing Ebola to the region, blamed foreigners for the ongoing spread in the Congo, and recommended false cures such as eating bitter nuts from the kola tree or bathing in hot water and salt.
In a study recently published in the Lancet journal, it was reported that over 90% of 961 interviewees from Beni and Butembo (two cities affected by the virus) had heard either that Ebola did not exist, or that it was fabricated for financial gains or to destabilise the region.
These rumours became foundations for belief in some citizens, as the same study reported that less than a third of interviewees felt that they could trust official authorities, and more shockingly that more than 25% believed that Ebola was not real.
Tragically, this led to targeted attacks on medical centers treating patients with Ebola, and contributed to the widespread distrust of health workers, reluctance to seek health care, hesitancy to accept the vaccine, and a lack of engagement in general protective and preventative behaviours that would have helped to stop the spread.
The fast spread of misinformation through social media has also occurred during the current coronavirus pandemic. For example, did you hear over the last few weeks that:
The army was about to shut down London?
People were in hospital because they took ibuprofen when they had the virus?
You can tell if you have the virus by how long you can hold your breath for?
Oh, and let’s not forget to mention that gargling water for 15 seconds can cure you?!
We’ve both been sent some combination of these messages via social media platforms like WhatsApp and Facebook, and a number of dangerous conspiracy theories have also been circulating.
You can read a blog from a fellow InSPIre the Mind writer who is writing a series debunking such myths.
So, we guess the next big question is: how can governments and public health officials fight conspiracy theories and dispel false claims that so often mislead people about the risks they face and how to protect themselves?
Well, it’s complicated.
Research in behavioural science suggests authorities are likely to face an uphill struggle to maintain public trust whilst ensuring their own clear and authoritative guidance, as our use of social media to share information continues to increase.
During the Zika outbreak in Brazil in 2015, two online experiments showed how efforts to counter misperceptions about diseases during epidemics can be counter effective.
The researchers found that providing corrective information to the public that had been adapted from the World Health Organisation not only failed to reduce misconceptions about Zika, but actually reduced levels of confidence in their beliefs about the disease that were actually correct.
Providing corrective information also contributed to panic and uncertainty in this particular case.
Taken together, these examples show that, to ensure capability, it is exceptionally important that the public receives accurate information and clear guidance from a trustworthy source (e.g., Public Health England/ World Health Organisation) at the earliest possible timepoint, so as to reduce the potential for speculation.
Opportunity
Regarding the “opportunity” aspect of the model, we noted several examples showing how a change in social norms or a removal of social barriers can affect behaviour in a positive way during outbreak scenarios.
One example occurred during the HIV outbreak in the 1980’s.
Amongst the UK public, there was a lack of understanding as well as misinformation about how the HIV could be transmitted. This led to large amounts of unjustified AIDS phobia and homophobia.
At the time, the Los Angeles Times conducted a poll and found that 50% of respondents voted in favour of quarantining people with AIDs and 15% wanted individuals with AIDS to receive a tattoo to make it apparent to other members of the public that they carried the disease. Shocking statistics.
Princess Diana famously acted to change widespread beliefs about AIDS and attitudes towards people who had contracted HIV when she made a public appearance to open the first specialist HIV/AIDS unit.
Without wearing gloves, she was photographed shaking hands with nurses and doctors working on the ward, as well as a patient on the ward who was suffering from the illness.
These images became headline news at the time, and Diana was able to publicly challenge the notion that HIV could be passed from person to person by touch, which was widespread at the time.
This contributed to a change in culture and a greater opportunity to enact safe and appropriate health behaviours.
Another example occurred in Hong Kong after the SARS outbreak in 2002.
From a stage at a busy shopping centre, the paediatrician Alvin Yee-Shing Chan broke out in song, reminding people to use gong fai — which is Cantonese for “serving chopsticks” — rather than using the same pair to serve and eat with. The same message: “Dine with serving chopsticks. Thou will not be sick” was promoted via television adverts.
The Hong Kong Medical Association also gave away 150,000 pairs of neon orange chopsticks at hospitals and doctor’s offices.
In order to increase hygiene and stem disease outbreaks, restaurants began to provide guests with two pairs of chopsticks that were decorated with different colours and accompanied by clear instructions: One pair is intended for serving food from a central sharing plate to your own plate, and the other pair is used to pass food from your plate to your mouth.
This custom increased in prevalence and gave guests the physical opportunity to change their behaviour.
Motivation
Regarding “motivation”, the importance of initiating enough worry for the population to act was demonstrated in a study looking at behaviour during the Swine Flu outbreak in 2009. The research attempted to understand why not enough protective behaviours were taken up by the public during this time, and why vaccination rates were low.
The national survey conducted at the time concluded that this was partly down to the low level of public worry about the possibility of catching swine flu. The same study found that motivation to perform a protective behaviour, such as handwashing, was linked to the level of belief that it would be effective against swine flu.
On the other hand, whilst a little worry can be motivating, too much can have a negative impact when attempting to tackle an epidemic.
Public health campaigns have been used since the 80’s to support HIV education and prevention, but despite this, nearly a million people globally still die from the virus every year.
In a review of research from Australia, Canada and the UK, fear of a positive diagnosis and internalised stigmatisation were commonly reported as barriers to testing for HIV.
Today, the UK-based “It Starts With Me” campaign aims to reduce fear and stigma by explaining that it is possible to live a long and healthy life after a positive diagnosis, and that testing should be part of a regular sexual health routine.
The campaign also shows that it is easy to get tested for HIV — “a finger-prick test is all it takes” — and that this can even be done at home, by using a postal kit. These messages may target reflective motivation by improving people’s beliefs about their capability and the opportunity to get tested.
Part one of our two-part series has demonstrated that the application of behavioural science is vital when considering human behaviour during a pandemic.
We can learn from past experiences and theoretical frameworks allow us to systematically develop and evaluate interventions.
Stay tuned for part two of this series, where we explore responses from government and public health authorities to the current COVID-19 outbreak.
All in all, this is a challenging time for all of us affected around the world. We would both like to extend our gratitude to all of the frontline workers, social distancers and public health heroes.
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