AUSTRALIA’s Chief Medical Officer Brendan Murphy has said “we don’t know if and when a [medical] vaccine will come”. If it does not come, or if it takes the expected 12–18 months, we will have to utilise flexible methods to minimise and contain outbreaks and prevent a second wave. This suggests that, for the foreseeable future, we will need effective public health and hygiene procedures to protect us from new outbreaks.
Thus, the World Health Organization has communicated guidance, highlighting criteria for slow, controlled methods needed to relax restrictions. Steps 1 to 5 involve infectious disease control measures, which public health specialists are already addressing. To implement step 6, communities need to be “fully educated, engaged and empowered to adjust to the ‘new norm’”. This will rely on every person playing a crucial role in adopting and sustaining new adaptive behavioural patterns for personal and community protection.
So, while we await a medical vaccine, everyone will need to adopt and sustain what can aptly be described as a “behavioural vaccine” to keep us all SAFE: ‘Sanitise – Apart – Face – Elbows’ (Table 1).
|Primary strategy: establish routines and habits
|If/then strategy (when primary strategy not possible)
|Clean hands for 20 seconds with soap and water
|The virus cannot live without transmission into the human body; using soap or detergent to clean your hands and the surfaces you touch kills the virus
|Keep soap next to sinks and carry hand sanitiser. Sanitise your hands frequently throughout the day. Form new habits – always sanitise your hands:
– when coming into home/workplace from a public area (eg, train, shops)
– after coughing or sneezing
– after touching eyes, nose or mouth
– after shaking hands
– after touching public surfaces (door handles, handrails, elevator buttons, products in shops)
|If you shake hands with someone or touch a potentially contaminated surface (ie, one that you cannot confirm has been disinfected), then sanitise your hands
If handwashing facilities are not available, then use your own hand sanitiser (> 70% alcohol)
|Disinfect surfaces you use every day, especially if you have taken them outside the home (eg, wallet, phone, door handles, light switches, keyboards)
|The more space between you and others, then the harder it is for the virus to spread. Maximising the space between you and others and minimising the frequency with which you are physically close to others will reduce your risk of transmitting the virus
|Keep apart! Safe physical distance depends on your activity:
– stay 2 m apart from everyone you are not living with to avoid breathing in their breath
– stay 10 m apart when jogging or cycling slowly
– stay 20 m apart when cycling fast
|If it is not possible to maintain physical distance, or you touch or shake hands without thinking, then sanitise your hands, face and personal items as soon as possible
If you are momentarily less than 2 m from someone, then hold your breath and walk for a couple of steps before breathing again
|Keep a safe physical distance from others
|Avoid hugging or shaking hands when greeting people
|Avoid touching eyes, nose, mouth
|The virus can live on various surfaces for several days, and enters the body through the mucus membranes; not touching the face is a key way to minimise transmission of the virus
|To minimise touching your face, you are likely to need to form a new habit (eg, folding your arms, putting hands in pockets, keeping hands below shoulders)
|If you touch your face after being out, then sanitise your face and hands as soon as possible
|Cover sneezes and coughs with elbow or tissue
|The virus is transmitted through droplets in a breath, cough or sneeze. Catching coughs or sneezes in the inner angle of your bent elbow (or in a tissue that is disposed immediately) minimises transmission of the virus onto other people or surfaces
|Form new habits:
– carry tissues
– dispose of used tissues
|If you feel like sneezing, then use your elbow to cover your nose and mouth
This acronym identifies a set of four crucial behaviour changes, which need to be practised and socially reinforced across situations. These four behaviour patterns may seem easily enacted but they are actually challenging to apply consistently across contexts, for several reasons discussed below.
Keeping SAFE relies on effective communication
In order for the population to adopt a universal “behavioural vaccine” for coronavirus disease 2019 (COVID-19), behavioural science input will be needed to inform a strong and memorable public health campaign. It will need to acknowledge this complexity with persuasive, empathetic and timely messaging to build trust and enable new habits and routines to become established. The success and longevity of some previous public health campaigns offer some insights.
In Australia, the “Slip! Slop! Slap!” campaign, initiated in 1981, was iconic in influencing a generation to take care in the sun. Similarly, in the 1970s, the United Kingdom’s Green Cross Code taught road safety to a generation of children with “Stop, Look, Listen”. What these successful and enduring campaigns have in common is a focus on a specific behaviour that is both memorable and actionable by all individuals – “keep SAFE” has similar appeal.
Effective communication with communities will be essential. This will require communicators who can develop trust and offer credible leadership. This in turn depends on identification and empathy with audiences, including acknowledging challenge and loss. In this context, simple, consistent instructions that empower people to protect themselves and others can facilitate positive change.
Keeping SAFE relies on individual and systemic changes
As an example, handwashing sounds simple. However, studies demonstrate that a multifaceted approach is needed to sustain consistent handwashing over extended periods, even among health professionals who are motivated to minimise viral transmissions within hospital settings. Effective implementation of handwashing protocols does not just rely on the individual’s motivation, it also relies on their knowledge of effective handwashing techniques and the opportunity to act as regularly as needed (eg, sufficient time as well as the availability and replenishment of soap dispensers and hand sanitisers).
Keeping SAFE relies on forming and sustaining new habits
Research suggests that it can take weeks, or even months, to form new habits, and there is considerable variation in how quickly automaticity is accomplished, dependent on motivation, difficulty of the behaviour, and the situation. While it is challenging to create new habits, it can be more difficult to cease habitual behaviour. So, refraining from touching our faces (or surfaces in public areas) will likely require the adoption of an alternate behaviour (eg, folding arms, hands in pockets), which may have unintended consequences for body language.
Speedy and succcessful habit breaking or habit formation is facilitated by managing everyday behavioural and environmental triggers. “Nudges” are cues in the environment that can prompt and direct action. They are useful in helping people to form healthy new habits where current habitual behaviour is a barrier to the new behaviour. We are already seeing examples of nudges being applied during the COVID-19 pandemic; for example, waiting “spots” in supermarkets to encourage physical distance. Handwashing nudges have been applied successfully in schools and health care settings. In comparison with many health education or behaviour change interventions, nudges are typically low cost and implemented easily, but the content and placement of the nudges, their effectiveness, and any unintended negative consequences need to be ascertained.
Keeping SAFE relies on self-regulation
To date, in the COVID-19 pandemic, governments have used legislative changes as the main lever for modifying our social behaviour, and these measures have been deemed effective, but behaviour change is nuanced. For example, physical distancing is not a discrete behaviour, and legislation alone cannot keep people apart. Physical distancing requires community commitment, ongoing behavioural monitoring, self-regulation and decision making about life’s minutiae. For example, “should I get into an elevator if others are already inside?”, “should I go back to the shops for the milk that I forgot or do without to avoid a non-essential outing?” This places significant demands on our cognitive and emotional resources, even if we are already persuaded that staying “apart” is the right thing to do for the sake of our own and others’ health.
Indefinite physical distancing and self-isolation are examples of behaviour change that have significant potential for decisional fatigue, especially when perceived community transmission is low. Self-isolation typically leads to low mood and irritability, but can also cause sleep disturbance, anger, anxiety and depression. Thus, maintenance of this strategy is reliant on reducing or eliminating these negative emotional impacts through mobilisation of virtual social supports and engagements.
Keeping SAFE relies on people acting rationally
Behavioural science demonstrates that it is not simply a case of communicating a message and relying on people to act rationally. While people usually act rationally, and often altruistically, our actions are just as likely to be motivated by love, fear, anger, hedonism, habit or mental exhaustion. Indeed, the need to feel good may well have a negative impact on a person’s choice to remain a safe distance “apart” from loved ones, particularly at times of great joy or sadness and grief. Interestingly, people have a tendency to touch their faces more when they are anxious, embarrassed or stressed. In addition, there is a growing body of evidence to suggest that emotional dysregulation is implicated in risk taking and health compromising behaviours, which have long been considered to be driven largely by impulse and disinhibition. Consequently, emotion regulation will be an important predictor of a person’s capacity to “keep SAFE”.
Keeping SAFE by applying behavioural science
Immediate action is needed, so we must rely on existing scientific understanding of transmission-related behaviour and of the psychological determinants of action and habit formation. We will need new evidence from behavioural science specific to COVID-19 about:
- the barriers and enablers of each action for specific populations and contexts;
- how each action needs to be tailored for specific populations and settings;
- the intended and unintended consequences of these actions (eg, anxiety, stigma); and
- what behaviour change levers work best for each action.
We have proposed the case for a “behavioural vaccine”: “keep SAFE”. It is available immediately, highly affordable and effective, if implemented well. We have also demonstrated the complexity of the consistent enactment of the behaviours that constitute this “vaccine”. Of course, there are limits to this metaphor: there is no injection or comprehensive coverage. Instead, what we propose needs to be applied carefully, consistently and repetitively until elimination or cure is available. Effectiveness will depend on trustworthy, clear, consistent and powerful communication across society (by governments at all levels, organisations and individuals) and continual empathetic reinforcement. Behavioural science is central to planning communication and evaluation of the effectiveness of strategies to reinforce the “keep SAFE” behaviour.
Professor Jane Speight is the Foundation Director of the Australian Centre for Behavioural Research in Diabetes (Diabetes Victoria) and is in the School of Psychology at Deakin University.
Professor Timothy Skinner is with the La Trobe Rural Health School in Bendigo, and the Department of Psychology, University of Copenhagen.
Jessica Hateley-Browne is Senior Advisor with the Centre for Evidence and Implementation in Melbourne.
Professor Charles Abraham is the Director of the Melbourne Centre for Behaviour Change at the University of Melbourne.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.