Informing and translating the evidence base

The recent Covid-19 outbreak has brought behavioural science and the importance of human behaviour front and centre in the public consciousness. Susan Michie, Professor of Health Psychology and Director of UCL's Centre for Behaviour Change, and member of the UK Government's Covid-19 Behavioural Science Advisory Group, shares her thoughts on challenges and opportunities that accompany translating the evidence base to inform policy and population behaviour.

Sticking to the evidence-base

A significant challenge in providing behavioural science advice to policymakers in a pandemic is the practical limitations of reviewing and summarising evidence, sourcing expert opinions and bringing people together for discussions at breakneck speed. In an ideal world, several co-ordinated teams would be conducting rapid reviews of evidence to enable responses in timely manner to questions coming from Government ministers or other parts of the scientific and political community tasked with decision-making. In the future, evidence synthesis will be transformed by harnessing Artificial Intelligence, as in the work of the Wellcome-funded collaborative research project, the Human Behaviour-Change Project (www.humanbehaviouralchange.org; see also our January 2019 issue).

A second challenge is that the Covid-19 Behavioural Science Advisory Group is tasked with presenting evidence to the Scientific Advisory Group in Emergencies (SAGE) but is not currently engaged with the latter parts of the translation process, the written and verbal communication of scientific advice and behavioural advice for the general population. For example, there has been confusion as a result of vague, ambiguous and inconsistent messages, as seen in differences between NHS and Government written guidance and in the interpretation of guidance by different Government ministers. This undermines the likelihood that people will follow the guidance, and can cause anxiety, frustration and resentment.

Making guidelines behaviour specific

Guidance needs to be written in behaviourally specific ways, stating who needs to do what, when, where and how. The 'how' aspect is important as behaviours that are seemingly related are often very different, with different influences and requiring different strategies to change them. For example, there are four behaviours that, if everyone were to perform them, would quickly extinguish the Covid-19 pandemic (four components of a 'behavioural vaccine'). They appear simple but, in different ways, are difficult to change:

1. Hand-washing: this requires change in routine and noticing situations requiring action (e.g. coming into buildings, before preparing or eating food). Forming rules and if-then plans is an appropriate strategy.
2. Using tissues for coughs and sneezes: this requires having a tissue available when needed. Forming a habit e.g. when checking for keys and purse in pocket or bag, check for tissues. 
3. Not touching eyes/nose/mouth: studies show people do this about 20 times per hour often without awareness. To break this habit, developing a new incompatible behaviour such as keeping hands below shoulder level is needed.
4. Keeping two metres apart from those not in your household: this depends on your material and social circumstances such as your living and working arrangements and is likely to require Government-level policy (e.g. assuring financial security of all for staying at home).  

These behaviours may appear simple, but changing long-standing behaviours is far from easy. People will be more likely to adopt and maintain such behaviours if they have a mental model of the behavioural transmission routes (Michie et al, 2020). They are also more likely to be adopted if interventions are tailored where possible according to the needs and situations of different groups of people. If these behaviours changed across the population (as seatbelt use and smoking in public places have), the Covid-19 pandemic would extinguish. 

Frameworks to help understand and change behaviour

While behavioural science is informing government Covid-19 policies, there is also a role for behavioural science to inform the communication and implementation of those policies to maximise public understanding, engagement and adherence to advice. Being told what to do is not effective if 

• the communication is not clear, 
• you are not being told how to do it (e.g. the strategies mentioned above), or 
• you are not given the opportunity to do it (e.g in the context of Covid-19, those who are self-employed or paying rents can't afford to follow the advice to stay at home as they need income to buy food and other necessities). 

Even if you have the capability and opportunity, behaviour won't happen unless there is motivation to perform the behaviour. This is laid out in a simple model of behaviour, COM-B (Capabilities, Opportunity, Motivation, Behaviour), which postulates that for a behaviour to take place, a person needs to have the capability and the opportunity and the motivation – if any one of these are missing the behaviour won't happen (Michie et al, 2011, 2014). 

COM-B forms the hub of a larger framework, the Behaviour Change Wheel, a synthesis of 19 behaviour change frameworks identified in a literature review (Michie et al, 2011, 2014). It outlines nine different types of intervention that can be used to enable behaviour change: Education, Persuasion, Incentivisation, Coercion, Enablement, Training, Restriction, Environmental restructuring, and Modelling. The most effective interventions have been found to be those that operate at many levels (individual, community and population) and are sustained over time (NICE, 2007).  

The Behaviour Change Wheel has been used to structure behavioural science thinking about Covid-19. However, for policies to translate into practice in terms of population behaviours, much more than guidance and informational and motivational messages needs to occur. The social and physical opportunities to carry out the behaviours are central but often given insufficient prominence in policy-making. To change Covid-19 transmission behaviours, training is an important strategy – imparting self-management skills to change habits of a lifetime. A daily TV slot that everyone is encouraged to switch into demonstrating how to change the key transmission behaviours, the 'behavioural vaccine', could be a game-changer.  

Covid-19 is being tackled by structural, social and behavioural means. The final transmission pathway of inhaling droplets or touching one's eyes, nose or mouth with contaminated hands shows that the end points of transmission that needs to be blocked are individual behaviours: changing these across populations is key to solving the crisis we are now facing. 

References

Michie S, West R, Amlot R, Rubin J. Slowing down the covid-19 outbreak: changing behaviour by understanding it. BMJ Opinion, March 11th, 2020. https://blogs.bmj.com/bmj/2020/03/11/slowing-down-the-covid-19-outbreak-changing-behaviour-by-understanding-it/.

Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6(1):42.

Michie S, Atkins L, West R. The behaviour change wheel: a guide to designing interventions. London: Silverback Publishing; 2014. 

National Institute of Health and Clinical Excellence (NICE). 2007. Behaviour change at population, community and individual levels (Public Health Guidance 6), London: NICE. from http://www.nice.org.uk/Guidance/PH6.