Why we need to go beyond the handwashing problem to tackle COVID-19

COVID-19 means that behavior change tops policy makers and commercial strategist’s agenda to help protect our health & safety and financial & social well-being. There’s huge concern about how to encourage people to adopt simple behaviors, e.g. washing hands, or the use of hand sanitizer that are critical to at least slow down COVID-19’s spread.

The challenge of changing simple behaviors seems straightforward. Surely if there’s a known risk and a medically proven means to help mitigate it, we just need to tell people? Unfortunately, it isn’t that simple. Despite our hands routinely being sources of bacteria, even healthcare professionals don’t maintain an effective handwashing routine. 

The psychology of handwashing

Handwashing is a hard behavior to change, because hygiene habits are mainly learned in childhood so they’re typically highly routinized. Additionally, it’s hard to link preventive behavior and avoiding unpleasant outcomes, because poor hand hygiene doesn’t always result in illness but also the impacts may be delayed.

Many studies have examined different ways to create effective handwashing intervention strategies. It’s well known that awareness of the issue, while necessary, won’t significantly change hand-hygiene behavior alone. Other strategies have involved helping embed new routines by making access to handwashing easy and linked to other familiar behaviors so we find it rememberable. These studies typically suggest that these strategies do drive some positive change but it isn’t always sustained.

Are we motivated to change behaviour?

To adopt a new behaviour, we must be motivated to do so.  Many routines started out as the result of trial and error to work out what we liked or what worked well. Once we’ve done this, we’ve mastered our environment and can then concentrate on other things. 

Therefore, handwashing routines have evolved to be good enough for our environment. The challenge is motivating people to recognize that the environment has changed, and relearning is required to master new challenges. To change behavior, we must slow down our more automatic processing, disrupting routine responses that worked previously. We must encourage people to slow down and think more carefully about what’s needed for this new environment. But how do we motivate people to do this? 

Ways of motivating protective behavior

One aspect of motivation that’s often important in behavior change is identity, the kind of person you see yourself as. Many behavior change campaigns have drawn on social identity. One example of a successful identity-based behavior change initiative comes from Queensland, Australia which experienced a severe drought in 2006. To avoid water shortages, a campaign leveraged social identity by redefining what it meant to be a good Queenslander (i.e. one that saves water). The campaign successfully reduced water consumption and levels stayed low after the drought ended. 

Another aspect of motivation is that we’re 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’re very sensitive to their patient’s vulnerabilities. Researchers found that if they changed the messages that doctors and nurses received concerning hand washing and risk were directed to patient welfare rather than their own, healthcare professionals used significantly more soap and gel.

Motivations also play a central role in the construction of and, influences from, emotion. Many emotions are highly motivating, but one that’s relevant in this context is ‘disgust’ – which is often associated with disease and other areas which affect our health and wellbeing. Feelings of disgust help us avoid potentially dangerous items (such as water that is contaminated). There’s growing evidence that the powerful nature of disgust-based interventions encourages handwashing. 

Renata Porzig-Drummond and colleagues undertook a lab experiment and a field trial which involved placing graphic disgust-inducing posters in washrooms to see if they increased rates hand washing rates more than posters in other washrooms with similar information, but without graphic disgust-inducing content. They found that the disgust posters significantly increased paper hand-towels and soap usage, successfully slowing down highly routinized behaviors.

Understanding the motivations of behaviors relevant to COVID-19 may educate us in how we can slow down existing automatic processing that accompany current routines e.g. handwashing. In doing so, individuals may create a new understanding of their environment and how it’s managed. This type of motivation building activity may create new routines, that embed familiar, lasting principles.

From handwashing to protective behaviors

Motivational interventions can also positively influence behavior more generally. While handwashing is important for slowing down COVID-19’s spread, a wider range of other behaviors are also important.  A review of advice from the World Health Organization, Centers for Disease Control and Public Health England suggests 13 behaviors can help reduce transmission. If we focus only on handwashing then social distancing, face touching, sneezing etc aren’t tackled. Focusing on one behavior at a time is simply inefficient. Resetting people’s motivations and interrupting automatic behavior will be at the root of a broader shift in mindset and more complex behavior sequences.

Implications

Behavioral science is important in tackling COVID-19. However, we must ensure that we take a holistic approach to behavior change.  If we focus on the mechanics of changing specific behaviors, we won’t equip people to deal with COVID-19’s threat properly. People must be motivated to change their behavior more generally. By addressing wider motivations, we can enact a wider set of protection behaviors that can tackle the risk of COVID-19 exposure and expansion.