Article: 'Reshaping Behaviour and Systems in a Post-COVID Policy Landscape'

In this June 2020 article in Singapore's leading policy journal Ethos, the journal of the Civil Service College Singapore, CEI co-authors Mary Abdo, Managing Director, Jane Lewis, UK & Europe Director, and Dr Robyn Mildon, Executive Director, looked at how behavioural and implementation science could support COVID-era policymaking.

This article first appeared in Ethos Digital Issue 6, 3 June 2020.

Reshaping Behaviour and Systems in a Post-COVID Policy Landscape, 

We are currently in the early stages of the COVID-19 pandemic. Policymakers the world over have reacted to the immediate crisis with a range of measures intended to affect both individual behaviour and systems changes and slow the virus’s spread. Lockdowns, implemented across most countries, are an effective, if blunt, policy instrument to control individual movement and hence, the risks of transmission. Over the next few months, as countries ease off lockdowns and lift restrictions, we will be entering a new phase in public management of this pandemic: transitioning from one based on controlling individual behaviour directly, to one that relies on influencing behaviour and the way our society operates. This new phase will rely on organisations (such as businesses) and systems (such as health and transport networks) adjusting their approaches in ways that support desired policy outcomes.

For those grappling with how to adapt policymaking in this post-COVID landscape, there are rich global examples of how implementation science and behavioural science can inform approaches to influence behaviours and reshape systems.

Behavioural Science and Implementation Science: An Overview

In brief, behavioural insights emerging from behavioural science are an approach to policymaking that combines insights from psychology, cognitive science, and social science with empirically tested results to discover how humans actually make choices. Policymakers seek to influence those individual choices through approaches such as positive reinforcement and indirect suggestions—often collectively referred to as nudges.

Implementation science situates this individual behaviour within organisational settings and systems. Implementation science, which is newer to Asian policy contexts, studies methods and strategies to promote the uptake of interventions and innovations into routine practice—with the aim of improving outcomes for population health and well-being. The discipline is rooted in evidence about what it takes for a change both to achieve the intended results and to become business-as-usual, on a sustained basis. Implementation science is concerned with creating and embedding lasting change, recognising that it is common to see a “voltage drop” after a new programme is introduced, with initially positive results fading out over time. Implementation science is explicitly focused on understanding factors, processes and strategies at multiple levels—individual people, families, communities, organisations, and systems—and recognises that lasting change requires aligned effort at each of these levels. In every situation there will be aspects of the human and social setting that can help or hinder change. The smart work is in identifying these features of the setting and leveraging them purposefully and actively to support intended change.

Both sciences are rooted in understanding that change happens in social contexts , and that effective change strategies need to take account of, make use of, and align with the social dynamics of the context in which they happen. For example, they highlight the importance of social norms as an influence on behaviour and the effectiveness of the use of champions as a change strategy: people in organisations who can use their social networks and personal credibility to bridge between the desired change and its sustained implementation.

Key Lessons from Implementation Science and Behavioural Science

There is a range of approaches from implementation science and behavioural science that can be adopted to support long-term behaviour and systems changes in a post-COVID policy landscape.

1. Clarify and codify the behaviours you want to see
Critics1  blamed the Australian government in March when people flocked to beaches after the pandemic had already hit Australia’s shores, saying that messages from policymakers on appropriate behaviours had been confusing. A popular internet meme2  illustrated how confusing many find the public messaging, particularly in the early days of social distancing. In contrast, communication that came later in mid-May from the Government of Victoria was very clear on the “five reasons  you can leave home”3. If you want people to adopt a new set of behaviours, it is important to be very clear what those behaviours are. This is particularly important if behaviours are counter-intuitive. It is also increasingly important as the required behaviours become more complicated—as they will become when societies move on from the current restrictive lockdown arrangements to more varied arrangements. If people don’t clearly understand what they are supposed to do, they will struggle to do it.

2. Communicate the rationale for expected behaviours
Setting out the desired behaviours is not enough on its own. People also need to understand the principles and explanations behind them. This is important to secure commitment and motivation, as part of sustaining behaviours. In the end, new behaviours will be observed not just because they are required but because they make sense. Therefore, being clear about the rationale and principles promotes ownership and long-term adherence. Again, this is particularly important when the requirements become more nuanced and require a degree of interpretation. For example, when offices, factories and schools open again, it won’t be possible to exhaustively specify how each one of these organisations can operate safely in ways that apply to every setting and every circumstance. It will be important to set out the principles and rationale so that there can be some local interpretation and application. People use heuristics—mental shortcuts—all the time. If they understand the underlying principles, they can apply those heuristics in line with policymakers’ intentions. If they don’t understand the principles, their heuristics can easily lead to things going awry.

3. Appeal to values and what is “best for all”
It is difficult to sustain a change that feels at odds with your core beliefs about yourself, and many of the changes we have to make in response to COVID fit this category. Policymakers need to find a way of bridging that gap and, ideally, showing people how the required behaviours are in line with values and self-beliefs. This means reminding people of an aspect of their identity that connects with the required change. For example, once lockdowns are lifted, governments are likely–until acute risk abates—to continue to advise against social interactions with the elderly, given that they are a high-risk population. For many communities, a commitment to family values means commitment to caring for and honouring elderly relatives, which might normally include visiting them. Appeals to values should situate the desired behaviour–avoiding in-person social calls to the elderly—within the values system of the individual. For example, the core message that appeals to values while reinforcing the desired behaviour might be: “You care for your elderly relatives, and the greatest act of care right now is to keep your distance from them”. Effective communication around collective action that situates desired behaviour within the group interest can increase the likelihood of public-spirited actions: as a recent study4  finds, “it is the articulation of how the behaviour is “best for all”, rather than persuasion to undertake the specific behaviour, that most supports co-operation.”

In the end, new behaviours will be observed not just because they are required but because they make sense.

4. Implement behavioural nudges
Nudges are cues and messages that change the choice architecture and support individuals to make beneficial behavioural choices. In the context of a post-COVID policy landscape, the continued use of visual cues in public spaces will be critical. The most obvious of these is the use of tape to mark off the appropriate distance for queuing in public places, now implemented in public spaces from street markets in India5  to McDonald’s and Tesco in Britain6. There are many examples, some of them humorous: in Canada’s Yukon territory, the physical distance is described as one caribou length;7 at WeWork,8 washing hands to the tune of Billy Joel or Michael Jackson helped its members hit the recommended 20 seconds’ duration. The study9  cited above finds good evidence that the prominent placement of alcohol-based hand sanitiser increases use, while a recent online experiment by the Behavioural Insights Team in the UK found that bright infographics and minimal text on handwashing posters supported retention of key messages.10

5. Use data to shore up your messaging but make it crystal clear
The clear communication of data is an effective strategy in implementing behaviour and systems change. For example, it is difficult for many people to understand the exponential nature of potential infection through social contact, i.e., if you reduce your contact by half, you do much more than halving the number of potential infections. German Chancellor Angela Merkel’s clear communication of the R value of the virus is an example of how data simply and clearly explained can effectively communicate why individual behaviours are critical.11 Meanwhile, New Zealand Prime Minister Jacinda Ardern dramatically simplified pandemic messaging in a press conference targeted at children —whose behaviours governments must also think about shifting.12

6. Give people, and organisations, data on performance
Giving people data and feedback on their performance can improve compliance with desired behaviours. Programme implementation provides clear lessons: if individuals are clear about the desired target and know why it matters, then giving them data on their performance against the target is a key strategy for helping people then meet it. A Cochrane review13 of 140 randomised trials of audit and feedback in healthcare found that on average they showed a positive effect, with the top quartile having a relatively large effect of up to 16% on patient care. Some key approaches are needed to increase the impact of audit and feedback, including: audit criteria that is credible and in line with population benefit, using comparisons, setting goals that are realistic relative to current performance level, and providing actionable plans for improvement alongside feedback. In an example from the pre-COVID era, some hospitals introduced automated systems for tracking compliance with hand sanitiser usage, through the use of smart tracking devices that registered whether individuals had used hand sanitiser and then gave them warning buzzes if they hadn’t.14 Such approaches dramatically reduced hospital infections.

7. Use multiple strategies
It is clear from the science that one approach alone doesn’t work if you are implementing complex change. A single strategy might be sufficient if the required change is simple and its boundaries clear, but the more complex the behaviour, and the more it involves interactive and negotiated elements, the more a combination of strategies is likely to be needed.15 For example, a recent study showed that supporting therapists via supervision by also using active learning techniques such as role play, corrective feedback, and modelling was more effective than standard supervision alone.16 A longstanding review of teacher professional development revealed that—even when it involves demonstration, practice and feedback—training in a new approach achieves almost no discernible use of the approach in the classroom.17 It is only when strategies are combined—when training is combined with coaching—that a big difference is seen.18

Implementation science suggests using strategies that are appropriate to context. Influencing the “outer setting”—including policy context, inter-organisational networks and financial systems— involves strategies such as advocacy, communication, mandates, funding and financing.19 Influencing the “inner setting” or organisational context involves strategies such as leadership, capacity building, learning collaboratives, social networks and task sharing/shifting. These need to be aligned and used in concert to achieve complex social change. Too often, implementation strategies are guided by what Martin Eccles, a leading implementation scientist, calls the ISLAGIATT principle: It Seemed Like A Good Idea At The Time.20 Instead, policymakers need to use systematic approaches, such as implementation mapping, to plan and select strategies to support successful implementation.

8. Be curious
Governments cannot rely on the blunt instrument of controlling behaviour in the long term through lockdowns and citations, but need to consider how to influence behaviour and systems change. This means that effective systems will be fundamentally curious about and interested in individual behaviour and its drivers—and how and why behaviour and drivers change. This implies a greater focus on using data about “why” things are happening rather than just “what” is happening. Implementation science and behavioural science also emphasise the importance of co-creation of solutions with individuals implementing interventions. For example, approaches such as ethnographic studies21  and user-centred design22  are likely to be important tools in post-COVID policymaking, since long-term change will be dependent on richly understanding the drivers of human and social behaviour, and designing aids to behavioural change that are aligned with them.

These approaches from implementation science and behavioural science can help policymakers to plan beyond the immediate requirements of the lockdown and into the long, important process of sustaining behaviours to support public health outcomes.

Conclusion: Five Things To Know before You Start

While this piece has explored the potential of many approaches drawn from these rich disciplines, policymakers can focus on just five simple lessons before they begin to implement new interventions. First, be clear about your aim and the innovation. What change is needed, what are you trying to achieve, and what do you need people to do? Second, understand your context so that you can root effective strategies in the social interactions and contextual dynamics that will support them. Third, implementation is a team sport. Involve the people responsible for execution in the design and planning process. Fourth, be purposeful in your use of implementation strategies. Identify the barriers, identify the enablers, and choose and use strategies deliberately to address them and promote behaviour change. And finally, build for scaling and sustainability from the outset.

Implementation science and behavioural science are critical tools for policymakers’ skills sets in a post-COVID world. Using their lessons to guide approaches to behavioural and systems change can help support our societies in weathering this storm.

NOTES

  1. Jonathan Pearlman, (2020, March 24)“Coronavirus: As Australians Flock to Beach, Critics Blame Govt's Mixed Messages”, The Straits Times, March 24, 2020, https://www.straitstimes.com/asia/australianz/as-australians-flock-to-beach-critics-blame-govts-mixed-messages.
  2. Larry Johnson, “All of Mainstream Media”, tweet posted April 23, 2020, https://twitter.com/2LarryJohnson7/status/1253029416298582018.
  3. “Stay at Home Restrictions”, Victoria State Government, 2020, https://www.dhhs.vic.gov.au/stay-home-restrictions-coronavirus.
  4. P. D. Lunn, C. A. Belton, C. Lavin, F. P. McGowan, S. Timmons, and D. A. Robertson, “Using Behavioral Science to Help Fight the Coronavirus”, Journal of Behavioral Public Administration 3, no.1 (2020), https://doi.org/10.30636/jbpa.31.147.
  5. Sandip Dighe, “Pune: Mandai Finds Unique Way to Maintain Social Distancing among Veggie Buyers”, Times of India, 26 March, 2020, https://timesofindia.indiatimes.com/city/pune/mandai-finds-unique-way-to-maintain-social-distancing-among-veggie-buyers/articleshow/74819141.cms.
  6. Faima Bakar, “Please Pay Attention to the Tape Markings in McDonald’s, Tesco, Lidl and Other Stores”, Metro, March 22, 2020, https://metro.co.uk/2020/03/22/please-pay-attention-tape-markings-mcdonalds-tesco-lidl-stores-12437724/.
  7. Leyland Cecco, “Canada's Yukon Asks Residents to Stay One Caribou—or Four Ravens—Apart”, The Guardian, May 4, 2020, https://www.theguardian.com/world/2020/may/04/canada-yukon-coronavirus-caribou?CMP=Share_AndroidApp_WhatsApp.
  8. FOX TV Digital Team, “20-Second Songs You Can Use to Time Your Hand-Washing and Prevent the Spread of COVID-19”, Fox 2 Detroit, March 6, 2020, https://www.fox2detroit.com/news/20-second-songs-you-can-use-to-time-your-hand-washing-and-prevent-the-spread-of-covid-19.
  9. See Note 4.
  10. M. Egan, A. Mottershaw, G. Tagliaferri, Y. Xu, and V. Roy-Chowdhury, “Bright Infographics & Minimal Text Make Handwashing Posters Most Effective—Result from an Online Experiment”, The Behavioural Insights Team, March 23, 2020, https://www.bi.team/blogs/bright-infographics-and-minimal-text-make-handwashing-posters-most-effective/.
  11. Guardian News, “Angela Merkel Uses Science Background in Coronavirus Explainer”, video posted April 16, 2020, https://www.youtube.com/watch?v=22SQVZ4CeXA.
  12. Eleanor Ainge Roy, “Jacinda Ardern Holds Special Coronavirus Press Conference for Children”, The Guardian, March 19, 2020, https://www.theguardian.com/world/2020/mar/19/jacinda-ardern-holds-special-coronavirus-press-conference-for-children.
  13. G. Jamtvedt, S. Flottorp, and N. Ivers, “Audit and Feedback as a Quality Strategy”, in Improving Healthcare Quality in Europe: Characteristics, Effectiveness and Implementation of Different Strategies, eds. Busse, N. Klazinga, D. Panteli et al. (Copenhagen: European Observatory on Health Systems and Policies, 2019).
  14. CBS News & Associated Press, “Forget to Wash? Devices Track Hand Washing Adherence in Hospitals”, CBS News, 28 June, 2013, https://www.cbsnews.com/news/forget-to-wash-devices-track-hand-washing-adherence-in-hospitals/.
  15. G. Harvey, and A. Kitson, “Translating Evidence into Healthcare Policy and Practice: Single versus Multi-Faceted Implementation Strategies—Is There a Simple Answer to a Complex Question?”, International Journal of Health Policy and Management 4, no. 3 (2015): 123–126, https://doi.org/10.15171/ijhpm.2015.54.
  16. S. K. Bearman, R. L. Schneiderman, and E. Zoloth, “Building an Evidence Base for Effective Supervision Practices: An Analogue Experiment of Supervision to Increase EBT Fidelity”, Administration and Policy in Mental Health 44, no. 2 (2017): 293–307, https://doi.org/10.1007/s10488-016-0723-8.
  17. Bruce Joyce and Beverley Showers, “Student Achievement through Staff Development”, in Designing Training and Peer Coaching: Our Needs for Learning, Bruce Joyce and Beverley Showers (VA, USA: ASCD, 2002), https://www.unrwa.org/sites/default/files/joyce_and_showers_coaching_as_cpd.pdf.
  18. J. Showers, Training Components and Participant Outcomes, https://addictionhelp.org/wp-content/uploads/2015/01/JoyceShowers-sm.png.
  19. S. W. Stirman, C. A. Gutner, K. Langdon and J. R. Graham, “Bridging the Gap between Research and Practice in Mental Health Service Settings: An Overview of Developments in Implementation Theory and Research”, Behavior Therapy 47, no. 6 (2016): 920–936, https://doi.org/10.1016/j.beth.2015.12.001.
  20. S. Michie, H. L. Gainforth, and L. Atkins, “Changing Behaviour to Improve Clinical Practice and Policy”, in Novos Desafios, Novas Competências: Contributos Atuais da Psicologia, eds. C. P. Dias, A. Gonçalves, A. Azevedo, and F. Lobo (Braga: Axioma - Publicações da Faculdade de Filosofia, 2016), 41–60.
  21. “QU329—Ethnographic Research for the Director of Public Health Annual Report 20/21: The Impact of Covid-19 on Birmingham”, Bidstats, May 1, 2020, http://bidstats.uk/tenders/2020/W18/726007987.
  22. S. Ayyar, (2020, April 2). “COVID-19: 5 Human-Centered Design Principles to Guide Leaders in a Crisis”, UX Magazine, April 2, 2020, https://uxmag.com/articles/covid-19-5-human-centered-design-principles-to-guide-leaders-in-a-crisis.