Sustaining COVID-19 Recommended

Behaviors for Extended Periods

Marsha L. Vanderford, PhD

HEALTH
EMERGENCIES
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 Change in mask-wearing in public* February – July 2020

100%
90%
80%
70%
60%
Italy
50%
Germany
40%
United States
30%
*Persons who
20% self-reported
mask wearing
10% in public in the
0% past 2 weeks
February 2020 July 2020
Based on data published in Bloomberg Opinion 16 July 2020 HEALTH
https://www.bloomberg.com/graphics/2020-opinion-coronavirus-global- EMERGENCIES
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face-mask-adoption/
 Mark all that are true

People will adopt recommended health behaviors:

 If they are aware of a disease threat
 If they believe they (or loved one) is at risk for disease
 If they feel confident in their ability to take actions
 If recommendations are in alignment with their beliefs and values
 If they believe others follow recommendations and expect them to do the
same
 If the resources needed to take action are accessible to them
 All of the above are true

HEALTH
National Academy of Sciences, 2020 EMERGENCIES
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 Fundamental gaps in RCCE literature Pre-COVID-19
• What elements of messaging are best at motivating actions to protect health?

• What elements of context influence people’s risk reduction behaviors?

– social, economic, political, and cultural factors

• Public health has limited experience on how best to maintain or reinvigorate

public support during a global health crisis that expands over months and
effects everyone.

HEALTH
Bosman, Mervosh, Santora, 2020; Communicating Risk, 2017 EMERGENCIES
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 Learn from our colleagues in behavior change
communication and other social sciences
Behavior-change communication, health economics, behavioral economics,
psychology, public health campaigns, social science, health promotion, health
education
Behavior-change communication, health economics, behavioral economics,
psychology, public health campaigns, social science, health promotion, health
education

Every move counts video: WHO: https://www.who.int/multi-media/details/every-move-counts

Designated Driver is the life of the party poster: https://www.hsph.harvard.edu/chc/harvard-alcohol-project/
12 Tips to be healthy poster: WHO; https://twitter.com/who/status/911980139394797568?lang=en

Broken cigarette: WHO poster: https://www.who.int/news/item/22-09-2020-tobacco-responsible-for-20-of-deaths-from-

coronary-heart-disease HEALTH
Avoid drinking alcohol: WHO, WFP poster: https://www.who.int/images/default-source/health-topics/coronavirus/wfp-who-
alcohol-card.png?sfvrsn=ba606083_0 EMERGENCIES
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No smoking poster: WHO (Tobacco Free Initiative) poster: https://www.who.int/health-topics/tobacco#tab=tab_1
 How long is the road ahead?
(Choose the single best answer)

Less than a month Between 6-months and a

A few months year
A year
More than a year

Road to recovery

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 Trajectory of pandemic fatigue

Road to recovery

Spring 2020 Summer 2020 Fall-Winter 2020

Many people started strong: Growing public weariness + Efforts have given way
spurred by concern and urgency Increased risk taking to exhaustion/frustration

HEALTH
I-stock images used with permission EMERGENCIES
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 Non-starters: who else needs to be addressed?

“I am not at
risk”
Worldview at
odds with
recommendations

Marginalized
Fatigued
populations

Road to recovery

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Reaching the tired and demotivated

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Fighting pandemic fatigue by overcoming Status Quo
Bias

Status Quo bias

• We are happy with how we
routinely do things
• We do many things without
thinking (habits)
– Estimated more than 40% of our
Our habits actions we do without thinking
Habits
Status • Takes little effort
Quo • Unlikely to change
• Following recommendations is
harder work than following our
habits
HEALTH
Wood, 2019; Stockholm School, 2020. EMERGENCIES
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 Fighting pandemic fatigue: overcoming Status Quo
Bias
Fear and concern about
COVID-19 spread Fear and concern
were levers that moved
many people to follow recommendation--
over-riding their habits.

But fear loses potency over time

and repetition as a motivator. Our habits Old
Habits
Risk perception is lower as we
become more familiar with threat.

Wood, 2019; Witte, et al. 2000; Sreenivasan, & Weinberger, 2018 HEALTH
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 Fighting pandemic fatigue: make it easy
Without energy of fear and
concern

Change relies on will-power

Habits
Will power Will-power often fails to maintain
Our habits
behavior change

COVID-19 recommended
behaviors require repeated
actions everyday
HEALTH
Wood, 2019; National Academy of Sciences, 2020;
Stapleton, 2020; Hobbes, 2016.
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 Overcome status quo bias: Make it easy
*Cut the amount of time and
Example:
effort needed to perform a
“Hang your clean mask with your coat
and grab it as you leave the house” recommendation

https://unhabitat.org.mm/news/community-support-is-key-to-
successful-hand-washing-stations-to-combat-covid-19-in-myanmar

• Example:
install many hand washing or sanitizing stations
https://clipground.com/coat-rack-clipart.html in public areas so they are widely available.
*Tie new behaviors to already established ones
Hobbes et al. 2016; UN-Habitat, 2020; National Academies, 2020; HEALTH
Burns, et al, 2018; EMERGENCIES
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 Make it easier by building self-efficacy

Provide alternatives
Church Guidance,
rather than the “handshake of peace”
Bow instead

Make recommendations
rewarding enough
to encourage repetition
to create new habits
Source:
https://www.youtube.com/watch?v=8igi
https://africacdc.org/covid-19/
pyScrCI&ab_channel=Kin

HEALTH
Stapleton, 2020; National Academies, 2020; African CDC; 2020 EMERGENCIES
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 Be explicit (in this case, also fun/rewarding)

Clearer
Vague
• Socially distance
• Physically distance

Adapted from
Let’s stay one bicycle apart Sorannews24
Social Distancing
2m = in Japan
3-4 steps for adults https://soranews24.
5 steps for children com/2020/04/17/what-social-distancing
-looks-like-in-japan

HEALTH
National Academies, 2020; McGee, 2020; Duffin and Childs, 2020 EMERGENCIES
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 Nudging: Directing behaviors at the point of decision

• Small interventions redirect

behavior
– at point of decision-making
• Modify “choice architecture”
– make recommendations easier than not
following them
• Heighten salience
– by observing how others act Weforum.org

• Nudges help create new habits

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Stockholm, 2020; EURO, 2020; Halpern, 2015; EMERGENCIES
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Thaler and Sustain, 2008; Soete, 2020.
 A Nudging Analogy: Don’t Drink and Drive

Individual makes decision to

Drunk driver may not get hurt, but
drink and drive
innocent person suffers.
COVID-19

Individual makes a decision to Young party-goer is unknowingly infected but symptomless

attend a holiday party and exposes older person at home with severe illness
I-stock images HEALTH
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Duffin & Childs, 2020
What can we learn from nudging campaigns

Designated Driver COVID-19 Distancing/Masks

Changed the bar environment/experience How could we change the
environment?
Posted new signs in the bar: “We support not drinking/driving” What signs could be put in the
right places (at point of
decision)?
Offered free bar food for those who are designated drivers. What incentives could be
offered?
Posted signed commitment forms required to get reward What kind of commitment
mechanisms could be used?
Made non-alcoholic drinks easier to see How can we make
recommendations easier?

HEALTH
National Academies, 2020; Duffin & Childs, 2020
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NON STARTERS

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Opposing Worldviews and Ideologies

Sometimes science challenges people’s deeply held

beliefs and values

Ideologies
• Influence understanding of science
• Acceptance of messages
• Use of scientific information in decision-making

Worldviews may be religious, political, or conspiracy

theories
National Academies, 2020; Bruine de Bruin and Bostrom, 2013; HEALTH
Chowdhury, et al. 2012 Bostrum, 2008. EMERGENCIES
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 Oppositional Worldviews: What doesn’t work

• Don’t try to change core beliefs

– Focus on behaviors instead
– Frame behaviors through their ideological values
• Don't overwhelm with more facts, evidence and data
– Makes group more resistant
• Avoid mandates and authoritarian directions
Key goal: don’t close down future opportunities

Levin, 2020; Duffin & Childs, 2020; Hersey et al., 2005; HEALTH
National Academies, 2017, 2020; Byrne and Hart 2009; Kahan et al., EMERGENCIES
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2010; Omer, 2020.
People who don’t feel personally at risk

Ages under 60
much less severe
disease

More optimism bias

Individuals with more

individualistic and less
collective values

https://ourworldindata.org/mortality-risk HEALTH
-covid#case-fatality-rate-of-covid-19-by-age EMERGENCIES
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 Use social norms and peer pressure

Influenced by
• What they see others doing
• What do others approve of

Related communication tactics

• Visible nudging
• Messages that reinforce large of people following recommendations
• Messages that highlight majority approval of recommendations
• Avoid undue attention to frequency of socially undesirable behaviors
• Examples of other low-risk groups endorsing recommendations
HEALTH
Bavel, et al., 2020; National Academies, 2020; Murrar et al, 2020;
Stockholm School, 2020.
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 Social pressure:
highlight everyone wearing a mask

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Marginalized and Underserved Groups

Social inequalities increase

• risk of infection
• inability to adopt recommendations

Economic position and racial inequality are also

associated with
• distrust in social institutions (inc. health system)
• Less willing to adopt recommended behaviors

Factor equity into strategies for increasing the

adoption of protective behaviors

HEALTH
Holmes, 2001; Stapleton, 2020; Templeton et al., 2020;
Bavel et al., 2020)
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 Best approaches to marginalized groups:

• Tailor health information specifically for marginalized

groups
• Engage agencies that are trusted by marginalized
groups to share information about COVID-19 risks and
recommendations
• Monitor news and social media channels preferred by
marginalized groups to identify circulating rumors and
misinformation
• Use testimony from others in the group who didn’t follow
recommendations and became ill, who are now
encouraging others to follow recommendations

HEALTH
Bavel, et al. 2020 EMERGENCIES
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 Keep at it

Lasting change requires

sustained campaigns ,
-Wakefield, Loken, and Hornik, 2010.

Road to recovery RECOVERY

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THANK YOU

HEALTH
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