Interview with Professor Susan Michie, Professor of Health Psychology and Director of the Centre for Behaviour Change at University College London (UCL), and a member of the UK Scientific Pandemic Influenza Group on Behavioural Science (SPI-B): 2019 Novel Coronavirus (COVID-19).
How does people’s behaviour affect the spread and containment of an infectious disease, such as COVID-19? What role can behavioural science play?
Susan Michie: Behaviours are part of systems of behaviours between individuals and within individuals, with some behaviours enabling or hindering others. People belong to social networks, family groups and organisations, through which changes in individual behaviour scale up to the population level. Personal protective behaviours, such as cleaning your hands, not touching your eyes, face and nose, and using tissues and disposing of them appropriately, are behaviours for which individuals can take responsibility. If everybody — individually — did those, together with social distancing, viral transmission would stop dead in its tracks.
We need population-wide individual behaviour change so that, for example, not cleaning your hands when entering a building or before eating becomes to be seen as antisocial in the way that spitting currently does. The first step to changing behaviour is to understand behaviour in its context, meaning that behavioural science should be at the heart of efforts to reduce disease transmission, and, indeed, all threats to health, the environment and society.
Why do people comply or refuse to comply with responsive and preventative actions put out by authorities, such as hygienic norms, social distancing, quarantine and vaccination, and how can they be encouraged to behave accordingly?
Susan Michie: For any behaviour to occur, people need to have the capability — the physical (e.g. strength and stamina) and psychological ability (e.g. the knowledge and skills) to enact the behaviour, both the physical (e.g. resources) and the social (e.g. norms) opportunity that enable the behaviour, and the motivation which involves ‘reflective’ (e.g. conscious, deliberate decision-making) and ‘automatic’ (e.g. emotion and habit) processes that activate or inhibit behaviour. These three influences interact to generate behaviour and changes in behaviour in turn can have an impact on these influences. This simple, comprehensive model of behaviour in its context is called “COM-B” (Capability-Opportunity-Motivation-Behaviour).
Behaviour will not happen unless all three of capability, opportunity and motivation are in place. For example, you can have the ‘reflective’ motivation path driving you towards a particular behaviour because you believe that enacting the behaviour will protect yourself and others. However, that behaviour may be undermined by the ‘automatic’ path of your motivational system due to your habits, needs and wants, or by lack of knowledge and skills, or by opportunity. The lack of opportunity, for instance, may involve not having access to water and soap or hand sanitiser in order to wash your hands, which is the case in many communities across the world. There are many reasons in which the intention to behave in a certain way is undermined by other aspects of one’s ‘behaviour system’.
To sustain behaviours, people need to develop routines and habits, reinforced and enabled by their physical and social environments. There are differences between people’s capability, opportunity and motivation, depending on, for example, their age, gender, employment and living conditions. Therefore it is important to tailor messages and interventions to particular groups and contexts. To generate more effective interventions and policies, there should be more citizen engagement and citizen science to harness the richness of the public’s thinking about problems, generating solutions, and designing and evaluating interventions.
When enough people begin routinely adopting personal protective behaviours and enough messages support these coming from a variety of trusted, high-status sources that people identify with, such as musicians, actors and athletes, then these behaviours can become a cultural and social norm. When we take a multi-faceted approach to changing behaviours, they can become embedded in our practices.
When and why do people go against their personal objectives and interests for the greater good? What is happening in this current pandemic?
Susan Michie: People’s decisions and behaviours will be influenced by the extent to which they think there is a threat and the extent to which they think they can do anything to mitigate it. They will examine the consequences of adhering or not, and how severe these consequences are. If people perceive a serious threat, then they will adapt their behaviour often to considerable degrees as we have seen over the last few weeks. We are, as a species, highly adaptive. People have already made huge sacrifices — some more than others — but they have overwhelmingly adhered to what have been very challenging restrictions. We have seen incredible altruism, generosity and helping behaviour.
How can governments and health authorities achieve the desired behaviours from the public during an infectious disease outbreak? What are effective behaviour change interventions and policies?
Susan Michie: The first step in changing behaviour is to identify precisely what behaviours are involved—who needs to do what, when, where and how. Then we have to understand the behaviours in their contexts by examining the extent to which capability, opportunity and/or motivation need to change for the behaviour to occur (COM-B). On that basis, a broader framework known as the Behaviour Change Wheel (BCW) will point to nine different intervention types to change the target behaviour and seven policy options that can support the delivery of the interventions.
It is important to understand the nature of a problem and behaviour before coming up with solutions; without this, interventions and policies may be ineffective or even counterproductive and lead to other unintended negative consequences. Evidence also suggests that to develop effective interventions and maintain change over time, a multi-level and sustained approach is needed which operates simultaneously and consistently at the individual, community and population level.
In many countries, despite personal protective behaviours being included in government advice, little guidance, training or support is given to promote adherence – we need guidance not just on what to do, but on how to achieve those changes consistently and for the long term. Personal protective behaviours are critical to limiting the virus’ transmission. To enable their adoption across populations, governments need to give more than advice and motivational messages to do them; explanation of underlying principles, skills training and enabling social and material environments need to be provided.