On Thursday 12th March 2020, the prime minister of the UK gave a speech outlining the strategy for delaying the Covid-19 pandemic[1]. In this speech, the British public heard the important advice about hand washing and the potential to cancel mass gatherings. What surprised many people was the delay in the UK government initiating many of the practices other afflicted countries had been adopting, such as an outright ban on public events, or an enforced working from home for office workers. Indeed, over the following days many large events, such as a popular half marathon races[2], still went ahead as planned. 

The UK approach to managing Covid-19 has contrasted with other countries such as Taiwan and South Korea, who acted much more quickly to the potential threat, likely due to past recent experience with the SARs outbreak[3]. Indeed, Taiwan in particular has been extremely robust in its response, with the Taiwanese Government used measures such as combining travel history data with identification card data to identify those who might have been exposed to the virus[4], quarantining those with any symptoms immediately. Elsewhere, Italy has the most deaths of any country surpassing China[5] at time of writing. Italy is particularly at risk as they have the oldest European population[6]. In response, they have put strict lockdown conditions in place. Those who leave their residence must have a signed form outlining their reasons for their journey, or face fines[7], for example. 

Similarly to the UK, the reluctance of the US Government to enforce strict isolation measures had been much slower than expected, with problems in enabling testing of large numbers of cases[8], with some states, such as New York, enacting lockdowns on their own[9]. However, apparently uniquely to the UK, the British government strategy had been informed not only by medical advice, but also advice from Behavioural Science through the Behavioural Insights Team, also known as the “nudge unit”[10]. At Cello Health, we have our own behavioural sciences team, who are well aware of the usefulness of using nudges to influence a specific behaviour – for example changing the default of the pension system to automatic enrolment, rather than having to set up your own pension[11].  

However, in a few short days that advice changed. The briefing on 16th March 2020 advised working from home for those who could, all “unnecessary social interactions” discouraged[12]. The UK public were told infections were accelerating and we were entering the “upward curve” phase of the pandemic[13]. Many of the public, however, were scandalised by the government relying on the advice of non-medical professionals advising the Government response to the outbreak[14].   

The usefulness of behavioural science in informing public policy has been called into question. Unfortunately, this criticism can reflect negatively on the role of behavioural science and its influence on understanding and implementing behaviour change. Part of this rests on the tendency to focus on the sub-discipline of behavioural economics and nudge theory. This is disappointing and fails to appreciate that the science of behaviour is much broader and inclusive of empirical evidence from other disciplines. A number of us within Cello Health work together to inform our clients of insights using the science of behaviour. We are disappointed by the continued way behavioural science has been pigeon-holed to focus on ‘biased’ and ‘heuristic’ behaviours.

Nudges are just one behavioural science tool, and involve making small changes to communications and environmental design to influence behaviour. These changes make use of psychological influences and biases to guide people towards more desired behaviours – e.g. placing healthier items at the top or bottom of restaurant menus in order to make them more likely to be chosen[15]. The idea behind this is while we are still giving people the choice to act how they wish, we are encouraging them (nudging them!) to choose a certain option. Influencing behaviour this way can have a huge incremental effect, especially on increasing the likelihood of behaviours critical to preventing the spread of infections, such as washing hands[16]. 

Utilising this thinking, the UK Government have strongly pushed the message of washing hands for 20s with soap and water as a key way to help prevent spread the Covid-19 virus[17]. This message that this is approximately the length of singing happy birthday twice[18] also helps people more likely to stick to the duration required, so maximises the chances that it will be understood and engaged with. Additionally, the Behavioural Insights Team has identified possible behavioural intervention strategies to help people reduce face touching[19].

But we recognise its limitations. As Richard Thaler said in a recent Twitter post, “..No [sic] nudging will not solve the problem. In the US we need testing most of all. But it can help. Don’t shake hands. Wash them instead.” But we will not be able nudge everyone, and the effects of nudges are limited anyway, as Professor Olivier Klein points out in his excellent blog post for The Psychologist[20]. A wider issue also is the role behavioural science can and should play in a government’s strategy. We can’t ignore the reproducibility crisis[21] that’s happening within Psychology for example, so it feels shaky ground to seemingly build a whole strategy on. 

At this time, more than ever, transparency is needed. At time of writing, nearly 600 behavioural scientists signed an open letter addressing their opposition to the UK government’s initial decision to not implement measures of social distancing[22]. The group oppose the idea that this was not been implemented due to the UK Government’s concern around “behavioural fatigue” – another of the nudge unit’s ideas. The idea was that, if lockdown was implemented too early in the outbreak, there may be non-compliance as people get fed up of being limited and will go back to their old behaviour, which will then undermine the rationale of distancing when we need it most. Not only would we feel fed up, but the stress and loneliness isolation can bring needs to be considered too. However ‘behavioural fatigue’ appears not to be based on evidence[23] and has left many questioning if this is a sensible strategy, or in fact, a dangerous gamble based on little evidence. The letter urged transparency around the evidence base, and at time of writing there has been none offered. “Keep calm and carrying on” was unlikely to cut it in in this unprecedented pandemic scenario. 

Finally, after the delay in implementing stricter measures, the UK Government responded by imposing stricter lockdown measures this week, asking everyone to stay at home except for a small number of exceptions, or risk a fine[24]. A WHO expert believes this was around 10 days later than it should have been[25] based on the infection rates. Meanwhile the US appears to be going in the opposite direction, with President Trump aiming to open up large areas of the country by Easter[26], despite surpassing China as the country with the highest number of confirmed cases of COVID-19[27].

Regardless of whether the assumption of behavioural fatigue proves correct or not, behavioural science still has an undoubtedly critical role to play in guiding us through this difficult time. The role of ‘nudge theory’ is relevant but limited, not least as it focuses on considering individualistic, self-interest needs. Clearly, we need to go beyond the nudge. Other areas of the discipline, like social psychology and anthropology, may offer clues about how to understand and influence culture towards a greater collectivism in adhering to social distancing. People – and their behaviour – occurs in the context of cultural norms and social relationships. We cannot ‘nudge’ our way out of COVID-19, but we can use behavioural science to help measures ‘stick’ or be more effective.

As this situation is changing rapidly, please check back for future articles on behavioural science and the COVID-19 epidemic. 

Thanks to the rest of the Cello Health Behavioural Science team for their input on this post, especially Paul Mannu for his thoughts.

References

[1] https://www.gov.uk/government/speeches/pm-statement-on-coronavirus-12-march-2020

[2] https://www.bbc.co.uk/news/uk-england-bristol-51893095

[3] https://www.theguardian.com/world/2020/mar/21/coronavirus-asia-acted-west-dithered-hong-kong-taiwan-europe

[4] Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA. Published online March 03, 2020. doi:10.1001/jama.2020.3151 (link)

[5] https://abcnews.go.com/International/italy-coronavirus-death-toll-surpasses-china-task-force/story?id=69704673

[6] https://abcnews.go.com/International/italy-coronavirus-death-toll-surpasses-china-task-force/story?id=69704673

[7] Paterlini Marta. On the front lines of coronavirus: the Italian response to covid-19 BMJ 2020; 368 :m1065. (link

[8] https://www.sciencemag.org/news/2020/02/united-states-badly-bungled-coronavirus-testing-things-may-soon-improve

[9] https://www.forbes.com/sites/stevedenning/2020/03/22/why-the-us-coronavirus-strategy-must-change/#70d5e452e049

[10] https://www.bi.team/

[11] https://www.ifs.org.uk/publications/10271

[12] https://www.newscientist.com/article/2237619-coronavirus-people-in-the-uk-must-avoid-unnecessary-social-contact/

[13] https://www.bbc.co.uk/news/uk-england-london-51910748

[14] https://www.theguardian.com/commentisfree/2020/mar/13/why-is-the-government-relying-on-nudge-theory-to-tackle-coronavirus

[15] Dayan, E., & Bar-Hillel, M. (2011). Nudge to nobesity II: Menu positions influence food orders. Judgment and Decision making, 6(4), 333-342. (link)

[16] Czerniewska, A., & White, S. (2020). Hygiene programming during outbreaks: a qualitative case study of the humanitarian response during the Ebola outbreak in Liberia. BMC Public Health, 20(1), 154. (link)

[17] https://www.gov.uk/government/news/public-information-campaign-focuses-on-handwashing

[18] https://www.cdc.gov/handwashing/when-how-handwashing.html

[19] https://www.bi.team/blogs/how-to-stop-touching-our-faces-in-the-wake-of-the-coronavirus/

[20] https://thepsychologist.bps.org.uk/social-psychology-coronavirus-will-flies-save-us

[21] https://en.wikipedia.org/wiki/Replication_crisis

[22] https://behavioralscientist.org/why-a-group-of-behavioural-scientists-penned-an-open-letter-to-the-uk-government-questioning-its-coronavirus-response-covid-19-social-distancing/

[23] https://www.irrationalagency.com/post/what-is-the-role-of-behavioural-science-in-a-pandemic

[24] https://www.bbc.co.uk/news/uk-52012432

[25] https://news.sky.com/story/coronavirus-uk-should-have-gone-into-lockdown-10-days-ago-italys-scientific-adviser-warns-11964138

[26] https://www.theguardian.com/us-news/2020/mar/24/trump-coronavirus-us-easter-new-york-fauci-birx

[27] https://www.theguardian.com/world/2020/mar/26/coronavirus-outbreak-us-latest-trump