Going beyond handwashing to tackle COVID-19

COVID-19 means that behavior change has been thrust to the top of the agenda for policy makers and commercial strategists to protect our health and safely, as well as financial and social well-being.  There is huge concern about how people can be encouraged to adopt simple behaviors such as washing hands, these being critical to at least slow down the spread of the virus to minimize impact.

At first glance, the challenge of changing simple behaviors such as handwashing seems straightforward.  Surely if there is a known risk and a medically proven means to help mitigate it then we simply need to let people know?  Unfortunately, it is not as simple as it first seems.  Despite our hands routinely being sources of bacteria, even healthcare professionals fail to maintain an effective handwashing routine.

The psychology of handwashing

Handwashing is a hard behavior to change, in part because our hygiene habits are mainly learned in childhood so they are typically highly routinized and automatic.  In addition, it can be hard to  recognize any link between preventive behavior and the avoidance of unpleasant outcomes, because poor hand hygiene does not always result in illness but also the impacts may be delayed.

There has been a huge range of studies which examine different ways to create effective handwashing intervention strategies. It is well known that awareness of the issue, while necessary, is not sufficient to significantly change hand-hygiene behavior.  Other strategies have involved helping to embed new routines by making access to handwashing easy and linked to other familiar behaviors so we find it easy to remember.  The evidence from these studies typically suggests that these strategies can result in some positive change but also is not always sustained.

Are we motivated to change behaviour?

Given the importance of the issue and the challenges in involved in change behavior, it may be helpful to look at the issues from some fresh perspectives.   To adopt a new behavior, we typically need to be motivated to do so.  Many of our routines started out as being the result of trial and error to work out what we liked or what worked well.  Once we have done this, we have mastered our environment and can then concentrate on other things.

So, in a sense, handwashing routines have evolved in a way that have been good enough for the environment in which we inhabited.  The challenge is motivating people to recognize that the environment has changed and that some relearning is required as we have a new set of challenges to master, such as learning to remember to no longer do a cursory rinse of our hands but instead wash them for at least twenty seconds.  If we want to change behavior, we need to slow down our more automatic processing, disrupting routine responses that worked in the past.  We need to encourage people to slow down and think more carefully about what is needed for this new environment. The question is how to motivate people to do this of course.

Ways of motivating protective behavior

One aspect of motivation that is often important in behavior change is identity, the kind of person that you see yourself as.  There have been a range of behavior change campaigns that draw on social identityOne example of a successful identity-based behavior change initiative comes from Queensland, Australia which in 2006 experienced a severe drought. To avoid water shortages, a campaign was launched that leveraged social identity by redefining what it meant to be a good Queenslander (i.e. one that saves water).  The campaign not only successfully reduced consumption, but levels also stayed low even following the end of the drought.

Another aspect of motivation is that we are prosocial and often concerned about the consequences to other people.  Psychologist Adam Grant and colleagues found that healthcare workers tended to have an ‘illusion of invulnerability’ in their overconfidence about their own immunity to germs; however, they are sensitive to the vulnerabilities of the patients that they treat.  The researchers found that if they changed the messages that doctors and nurses receive concerning hand washing and risk were directed to patient welfare rather than their own, then heath care professionals used significantly more soap and gel.

Motivations also play a central role in the construction of and, influences from, emotion. There are many emotions which are highly motivating but one that may be particularly relevant in this context is that of disgust.  This is an emotion that has long been associated with disease but also for a range of areas which have significant implications for our health and well-being.  Feelings of disgust are often helpful as it means we avoid items that are potentially dangerous to us (such as water that is contaminated).  There is a growing body of evidence that the powerful nature of disgust-based interventions is actually effective at encouraging handwashing.

Renata Porzig-Drummond and colleagues undertook a lab experiment followed by a field trial which involved placing graphic disgust-inducing posters in washrooms to see if they increased rates of hand washing more than posters in other washrooms with similar information, but without graphic disgust-inducing content.  They found that the disgust posters were significantly more efficient at increasing the use of paper hand-towels and soap, appearing to successfully slow down the processing of these highly routinised behaviors.

Understanding the motivations relating to COVID-19 behaviors may well offer a successful means of slowing down existing automatic processing that accompanies current routines such as handwashing.  In doing so, individuals create a new understanding of their environment and how they can best manage it. This type of motivation building activity may then give rise to new routines, that embed familiar principles to make them last.

From handwashing to protective behaviors

Another advantage of using motivational interventions is that they have the advantage of influencing behavior in a more general way.  While handwashing is clearly important for slowing down the spread of COVID-19, there are a wide range of other behaviors that are also important.  A review of advice from the World Health Organization, Centers for Disease Control and Public Health England suggests 13 behaviors that are important to reducing transmission.   If we focus only on hand washing then we don’t tackle social distancing, face touching, sneezing and so on.  The process of focusing on one individual behavior at a time is simply not very efficient.  Resetting people’s motivations and interrupting automatic behavior will be at the root of a much broader shift in mindset and more complex sequences of behavior.

Implications

Behavioral science has an important role in tackling COVID-19 but we need to ensure that the discipline takes a holistic approach to behavior change.   If we focus on the mechanics of changing specific behaviors, then we are in danger of not equipping people properly to deal with the threats of COV-19.  People need to be motivated to change their behavior which means that ways of achieving this need to be clearly understood. By addressing these wider motivations, we can enact a wider set of protection behaviors that are necessary to tackle the risk of COVID-19 exposure and expansion.