Table 4 Preliminary analysis of options for enacting behaviours to limit virus transmission

From: Applying principles of behaviour change to reduce SARS-CoV-2 transmission

General principles with regard to types of intervention
1. Education: should focus on promoting understanding of the benefits of the behaviours and on how and when to enact them effectively, address concerns about the potential costs, and provide specific guidance on how to minimise adverse spill-over effects. It should take into account varying levels of educational level and varying circumstances.
2. Persuasion: should focus on generating a feeling of responsibility toward others in families and the community and a sense that the behaviours are valued by groups with which the target group identifies. It should promote concern and active engagement rather than anxiety and defensive avoidance.
3. Incentivization: should focus on use of social reward, including thanking people and praising them, to make people feel positive about having engaged in the behaviour.
4. Coercion: where threat of punishment is used, this must be accepted as appropriate by the community and applied in a way that is seen as equitable and proportionate. The contingencies should be clearly set out and explained. As far as possible any sanctions applied should be immediate (for example, on-the-spot fines). Use of social coercion should focus on the behaviour, not the person, and be delivered in a way that is perceived as supportive and just.
5. Training: should involve demonstrating the behaviour in full and component-by-component (including what to do and what not to do), provide a schedule for practice, and show common mistakes and how to rectify them.
6. Restriction: should involve setting clear and specific social rules around behaviours, with boundaries that are readily understood, explaining the rationale and providing specific examples of what is and is not acceptable.
7. Environmental restructuring: should involve redesigning indoor and outdoor spaces, include environmental cues that promote the behaviour, ensure that people have the material resources they need to enact the behaviours whenever required, create or provide access to physical spaces that support the behaviour, ensure that people have financial resources to sustain themselves and their families if they enact the behaviour, and ensure that social and organisational rules and norms are supportive of the behaviour.
8. Modelling: should show people with whom the target group identifies enacting the behaviour in ways that are culturally appropriate and realistic to achieve.
9. Enablement: should include a range of interventions for improving capability, such as therapeutic interventions to address mental health barriers to adherence, as well as interventions to extinguish or build habits and create if–then rules.
BehaviourAnalysis
Only cough or sneeze into tissues that are safely disposed ofEducation, training, modelling and enablement to improve capability, delivered through mass media, social media and online videos to show how to do this effectively and build habits, including ensuring that people always carry tissues with them.
Wear face masks as appropriateEducation, persuasion and modelling to improve capability, delivered through mass media and social media to help people wear face masks correctly in appropriate settings and ensure that they use them and dispose of them or disinfect them effectively. Training using online videos or delivered in person where practicable.
Maintain physical distanceEducation, persuasion and modelling delivered through mass media and social media, to motivate people to keep a specified distance where possible, and to encourage people to use social incentives to motivate other people they interact with to do the same. Supportive social coercion to discourage unnecessary proximity. Local restrictions regarding access to areas such as shops and parts of shops. Environmental restructuring to increase access to safe spaces and markings to show safe distances in areas such as queues.
Wash or disinfect hands under defined conditionsEducation, training and modelling delivered through mass media and key workers to ensure understanding of when it is necessary and how it should be done, using what cleaning agents. Environmental restructuring to ensure that hand sanitisers or washing facilities are available for people entering settings such as shops, workplaces and educational facilities where they touch objects. Enablement provided through online platforms to support people to set up personal if–then rules and habits.
Disinfect surfaces and objectsEducation, training and modelling delivered through online platforms to promote effective routines for cleaning surfaces and objects, especially in public spaces. Environmental restructuring to ensure ready access to appropriate cleaning agents.
Do not touch the T-zone unless one has just thoroughly washed one’s handsEducation and persuasion using mass media and social media to ensure that people understand the importance of not touching parts of their face if there is any chance they have touched a contaminated surface or object. Training and enablement using online platforms and in-person support to help people extinguish the habit and build conflicting habits, and to cope with facial itches without touching with a hand or part of the hand that may be contaminated.
Social distancing (staying at home except under specifically defined circumstances)Education, persuasion, incentivization, coercion, restriction and modelling are all needed to ensure strong motivation to enact the behaviour in the face of strong competing motivation. The messaging has to be precise and seen as personally relevant and include examples to counter exceptionalism. Coercive measures and restrictions need to take into account people’s need for a sense of agency. Environmental restructuring and enablement are particularly important to minimise negative spill-over effects and exacerbation of inequality. This must include financial and material resources and psychological support for people suffering from distress and mental health problems.
Isolation of people who have symptoms or who are highly vulnerableEducation to ensure understanding of how and why to implement and sustain isolation and how to achieve it in challenging domestic settings. Environmental restructuring to ensure continued access to financial and material resources. Enablement provided by key workers to provide tailored support to people in maintaining daily functioning and mental health.