Technical Advisory Group: sustaining COVID-safe behaviours in Wales

The Wales coronavirus control plan: alert level 0 (zero) notes ‘We will need to continue to think of others as well as considering the risk to ourselves in the way we live our lives. This means isolating and getting tested if we have symptoms; washing our hands and practising good sneeze etiquette; minimising the number of social contacts and time spent with them; meeting outside wherever possible and opening windows where we can’t; and wearing face coverings in crowded and indoor areas, including on public transport to protect others’. 

Furthermore, the plan has been designed based on principles that include: ‘help(ing) to embed long-term positive behaviours and trends linked to wider Welsh Government policy goals’. This is in line with recent advice published by, for example, SAGE (Sustaining behaviours to reduce SARS-CoV-2 transmission on GOV.UK and EMG, SPI-M and SPI-B: Considerations in implementing long-term ‘baseline’ NPIs on GOV.UK), and the Academy for Medical Sciences (AMS): COVID-19: looking ahead to winter 2021-22 and beyond.

These behaviours are clear, but neither knowledge nor intention to follow them alone necessarily leads to action. The multitude of cognitive, emotional, social and environmental influences on human behaviour need to be accounted for to ensure that they elicit and sustain appropriate personal protective behaviours. Co-ordinated society-wide approaches are needed to ensure that citizens and organisations in Wales have the capability, opportunity and motivation to engage in COVID-safe behaviours.

These determinants differ across society, as do the harms arising from the way COVID-19 has exacerbated existing, or introduced new, inequalities (The Health Foundation). Prioritising those with the greatest need, ensuring that interventions (communication, policy, services) match need, and do not generate inequalities themselves, has to underpin how we refashion core aspects of our lives.

Behavioural support priority

Figure 1 presents a high-level framework for how this approach could be enacted, underpinned with systematic definition and intervention design for each ‘Behavioural support priority’.

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1. Where there is immediate risk, physical changes to the environment and embedded behavioural cues will engender automatic COVID-safe behaviours;
2. Human decision-making is finite and effortful. Where risk depends on a dynamic and changing situation, ‘live’ situational decision-support can guide appropriate behaviour (STAN = “Space, Time, Air (ventilation), Number (of people)”;
3. Across the longer-term, education and collective action will help embed sustainable behaviours for future generations. HOT and COLD refer to the dual-process theory of behaviour (Thaler RH, and Sunstein CR (2009) Nudge. Penguin; Kahneman D (2011) Thinking, Fast and Slow. Farrar).

The purpose of this paper is to set out the core behavioural recommendations for sustaining COVID-19 safe behaviours for Wales. Its intended audience is wide, including those working on COVID-19 policy development and communications but also citizens and organisations, all of whom have a key role in keeping Wales safe. Having set out a high-level framework (Figure 1), the paper is organised around 6 key themes. While useful for presentational purposes, it is important to note these themes are not mutually exclusive, with a significant degree of overlap and should be viewed in this overarching way. Each theme is briefly introduced, followed by priority issues in bullet point form. This approach represents a synthesis of previously published advice from the Risk Communication and Behavioural Insights sub-group of the Welsh Government’s COVID-19 Technical Advisory Group (Behavioural insights to support a post fire break Wales, Using behavioural science to inform policy and practice, Priority considerations relating to personal protective behaviours to inform decisions on easing of restrictions in Spring 2021), observational work at a small number of test events in England and Wales (currently unpublished) and recent advice such as that from SAGE and the AMS noted above.

While uncertainties remain given the unknowns in dealing with a novel coronavirus, moving from a pandemic to endemic state will require populations worldwide to adapt to life with COVID-19. The success of the vaccine programme to date has already allowed the restrictions of the previous 18 months to be lifted, albeit cautiously. However, further effort across society will be required in the coming weeks and months, with everyone playing their part, including individuals, communities and organisations, with continued support from government. The ongoing work around supporting those who have COVID-19 or are a contact of a case (via the test and trace processes in place) will continue to be important. A ‘new normal’ may well also have seasonal variations given increased circulating respiratory viruses and possible new variants emerging. Recommendations:

• The support on offer in moving to a more open society will be more effective if underpinned by behavioural science.
• Encourage people to live their lives, while considering the risks, and providing the support necessary for them to do so.
• This support will need to recognise many people will still be worried about whether/when it will be safe to resume a more ‘normal’ way of life.
• Self-isolation of infected people is the most effective means of preventing transmission. Appropriate resources need to support this goal.
• Promote sustainable protective behaviours, for example staying home when ill, sneeze etiquette) as long-term habits and norms.
• It is important that individuals and organisations acknowledge that our behaviour is social and hence our individual decisions have implications for the wellbeing of others.

There is a substantial body of evidence illustrating how the pandemic has exacerbated existing inequalities and introduced new inequalities (The Deaton Review). Addressing these is of the utmost importance in both the ongoing pandemic response and in rebuilding as we move to an endemic state. While a long-term vision is required, a number of immediate recommendations can be identified:

• Identify and mitigate inequalities by, for example, addressing structural inequalities in self-isolating (e.g. financial, social and practical support) and differential rates of vaccine uptake, for example addressing specific barriers for defined groups.
• Routinely carry out impact assessments of policies and interventions, to account for equity and behavioural aspects.
• Increasingly work with underrepresented groups to identify challenges and co-produce solutions.
• Empower and resource local public health capacity including health and social care, local authority, education etc.

There is no such thing as a neutral message, and by understanding and harnessing the factors that influence communication efficacy we can better support the population of Wales by explaining how and why their behaviour is important in reducing COVID-19 transmission. Several key recommendations emerge when looking through the behavioural science lens, including the need to:

• Co-produce communications (self-relevance) and use credible, trusted messengers.
• Explain the WHY (to build intrinsic motivation); focus on rationale (transmission prevention, keeping life going); employ the ‘question-behaviour’ effect – ask pertinent questions, rather than issuing instructions or mandates.
• Celebrate and emphasise collective efforts within the population; acknowledge the value of shared identities and collective responsibility/goals, for example accentuating the positive stories around the sacrifices people have made to protect others, high levels of adherence to public health behaviours and the role of mutual aid groups (Cambridge University Press).
• Frame measures in terms of collective care and concern, and in collective and personal gains, rather than personal restriction.
• Place more emphasis on normalising protective behaviours and provide feedback, for example to leverage social norms of vaccine uptake. This could be through use of data, for example proportion of adults vaccinated (a large percentage) or recent numbers vaccinated by age band of focus, or use role modelling to support adoption of positive behaviours in target audiences.

Individuals and organisations do not always behave in line with their intentions (the intention-action gap). There are several ways to reduce this gap and support protective behaviours. Figure 2 develops the framework through which this can be addressed.

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Figure 2. Closing the intention-action gap. At one extreme, regulation and physical interventions can shape behaviours, sometimes to a large extent. For example, using one-way systems in a shop, or floor markings to assist social distancing, both ensure protective behaviour without the need for conscious awareness from the individual. At the other extreme, preventing someone from carrying out a behaviour until they have had time to rationally evaluate the situation helps to support intentional behaviour. For example, asking someone to think through a plan for their trip to the supermarket before they leave the house can reduce impulsive distractions and help an individual behave as they intend (and stay safe). Finally, in complex changing contexts then ‘live’ situational decision-support can help guide behaviour when our own bounded rationality is overwhelmed. System 1 and 2, and HOT and COLD processes refer to the dual-process theory of behaviour (Thaler RH, and Sunstein CR (2009) Nudge. Penguin; Kahneman D (2011) Thinking, Fast and Slow. Farrar).

Contextual recommendations

Intention-action gap: promote automaticity

• Shape the environment to support safe behaviour, for example reduce bottlenecks and create one-way systems to increase speed of flow.
• Use environmental triggers: external signals and primes are a major driver of pro-social behaviour.
• Use habits: longer-term adoption of routine protective behaviours.
• Use norms: promote/highlight new protective norms.
• Remove friction, for example walk-in vaccination centres, in densely populated areas, accessible on foot/public transport.
• Create defaults, for example provide hand hygiene stations near frequent-touch surfaces; employers routinely testing and enabling self-isolation of those with symptoms and cases.
• Continued emphasis on vaccination: an ‘automatic’ way to reduce transmission, while also reducing symptoms, hospitalisation and deaths.

Intention-action gap: promote intentions

• Planning: help people identify challenges and to plan to overcome them. Provide “if-then” advice to guide behaviour in different situations.
• Pre-commitment: make a (public) declaration or commitment to certain protective behaviours, useful for individuals and organisations/settings alike 
• Support new habit creation: for example setting specific goals, mental models (leave face coverings near keys) and encourage repetition (take a face covering every time you leave the house, leave shop door open when you open it).

Intention-action gap: situational risk and decision support

• Outdoors is safer, but indoors (with good ventilation) means transmission risk can be reduced.
• Assume social behaviour is predominantly automatic and so structure environment to drive protective behaviours.
• Assess the risk to you, and (if you have any) your customers/others using premises you control, then do what you can to reduce the COVID risk.
• Identify ways to support decisions in complex contexts. For example, can live CO² feedback give an indication of social density?
• Identify effective heuristics for relevant contexts. For example, can the use of a mnemonic such as “STAN” (space, time, air, number of people) help dynamic decision-making, recognising the bilingual nature of such heuristics will need consideration?
• Identify and signpost to Apps/Web that provide situational decision support, for example MicroCOVID.

There is utility in building acknowledgement and understanding that individuals’ own behaviour is shaped by what others do, and in turn impacts others’ lives and will do so even more in the future. Consideration of what each of us can do for ourselves, and for others, has increasing importance. Similarly, what can be expected from others in return, including workplaces, retail outlets, local authorities etc.

While recognising the importance of collective responsibility and a whole systems approach to moving to Alert Level 0 in Wales, greater emphasis is being placed on the role of individuals in making risk-informed decisions based on the everyday situations they find themselves in. These are the sorts of decisions we make multiple times a day but the pandemic has raised the profile of the importance of risk literacy (the ability to access, understand, appraise, and use risk information to make decisions that impact the life of oneself or others) among the population to help make choices that are as informed as possible. A number of key recommendations have been identified to improve risk literacy at a population level in order to live with COVID-19 as safely as possible and in making better risk-based judgements more generally.

• Raising awareness of how an individual’s behaviour and that of other people impacts on risk of transmission and particularly that this risk is often driven by unconscious behaviours.
• The importance of building risk literacy into the curriculum from an early age, including its integration into health literacy teaching more generally.
• While challenging, communicating uncertainty and the confidence in the evidence underpinning recommendations is critical for transparency of decision-making and building trust.
• The need for a strategic approach to risk communication that enhances accurate risk perception and risk literacy based on an established and rigorous literature. Incorporating existing approaches to identifying credible evidence, and identifying ‘fake news’.

The value of social and behavioural science in informing the pandemic response was recognised at an early stage (see Using social and behavioural science to support COVID-19 pandemic response from nature.com and Harnessing behavioural science in public health campaigns to maintain ‘social distancing’ in response to the COVID-19 pandemic from BMJ journals) and continues to inform communications and interventions. However, for this to continue and to influence the wider policy landscape relating to the recovery from COVID-19 and beyond, building capacity and capability within organisations is critical. This will require investing in social and behavioural scientists, building knowledge and developing skills across organisations and fostering collaboration between government, academia and the wider public, third and private sectors. Recommendations:

• In the short to medium-term, a theoretically driven approach based on behavioural insights has the potential to support COVID safe objectives.
• More broadly, building capacity and capability is vital for behaviourally informed communications, policy development and implementation.
• Such capacity and capability can support longer-term positive behaviours such as around sustainability, for example Well-being of Future Generations and Climate change

Dynamic and changing situations are the most risky. We have finite cognitive resources to evaluate risks in a ‘live’ situation. Many of us may not have adequate ‘risk literacy’ and hence an understanding of risk and behaviour. Therefore, heuristics can offer valuable support in complex situations.

When COVID-19 is prominent in our community, we should adopt the COVID-Code. This approach aligns with Independent SAGE work (to be published) not and reflects a common behavioural scientific acknowledgment of the importance of consistent and collective effort in reducing risk and harms in our communities. The COVID-Code draws the themes and actions from above together, and presents messaging that could be promulgated in the same way as the Highway Code was when first introduced. 

People sometimes argue it is not worth carrying out protective behaviours because they are individually ineffective. In response, we must encourage personal perceptions of efficacy and control over COVID-19, and emphasise that the combination of multiple protective behaviours and other interventions will prevent transmission of the virus. A popular metaphor here is Swiss Cheese. Whilst Swiss Cheese has holes in it, you cannot see through it. Likewise, with COVID infection control, whilst a single measure might not prevent transmission, the addition of multiple layers of actions and protective measures ensure safe environments. See Vaccines alone will not stop Covid spreading - here's why (BBC).

Always:

1. Stay at home (self-isolate) if you feel ill; if you have COVID-19 symptoms get a PCR test.
2. Self-isolate if you have COVID-19, or have been advised to do so by NHS Test Trace Protect.
3. Provide as much support as you can to help other people self-isolate.
4. Get all of your COVID-19 vaccines and boosters, and encourage those around you to get theirs too.

Where possible:

5. Minimise the number of face-to-face contacts you have, and the time spent with them.
6. Meet-up outside, but if you are indoors, open doors and windows.
7. Wear a face covering in crowded, and indoor, public spaces.
8. Wash/sanitise your hands regularly and always sneeze into your elbow.
9. Work from home when you can.

Whilst one action on its own may not stop the virus spreading, the combination of steps in the COVID-Code will prevent transmission if we each do our bit we will keep Wales safe.