I want to do a little thread on behaviour change theory (and how the government are absolutely fucking it), but also, strap in kiddos, and let's learn how to talk about behaviour change!

Behavioural science uses a model of behaviour which contains three ingredients: capability (feeling able to do the thing), opportunity (it's possible to do the thing) and motivation (wanting to do the thing). To change the behaviour, you need to change one or more components.

And for the behaviour to happen at all, you need all three ingredients - capability, opportunity AND motivation.

Now, let's start by looking at a reasonably successful adoption of a new behaviour: hand washing. Adherence is pretty high - a lot of people are washing their hands, and most people are doing it properly! Why?

Well, first of all, there's the capability. There was a pretty good information campaign about *how* to wash your hands, and the memes (remember those?) really helped spread the knowledge. So most people know how to wash their hands, and for how long.

Then there's opportunity. Everyone has a sink in their house, which makes doing it at home really easy. There's sinks in public loos, so where they're open, again the opportunity is there. Many shops have hand sanitiser stations at the entrance, and a lot of people carry it.

And the motivation is there, too. It's a simple message which makes people want to wash their hands: when you touch something, you might pick up virus particles. When you wash your hands, you wash away the virus particles.

So with hand washing, the capacity, opportunity and motivation are there and people are doing it for the most part (although worth noting that with public loos being mostly closed and sanitiser stations not being ubiquitous, there's more to be done on opportunity!)

Now let's use the model to look at something very few people are doing: covering their faces. Why would that be?

Firstly, capability: people are not taught how to use them. There's not even much education that you need to cover your mouth and nose, hence all the pokey-out noses. And don't get me started at how bad people are at putting them on and off - there's little about this!

How about opportunity? In theory, anyone who owns a scarf or bandana can do it, but there's very little education that the opportunity is right there in your home. And of course, disposable masks aren't handed out, and cute etsy ones are fairly pricey. So, little opportunity.

Finally, motivation. Dear god, I'm not convinced many people know *why* you should wear a mask, let alone *that* you should when you're in an indoor space or somewhere crowded.

Worth noting the BLM protests did a good job on mask adherence and ticked the COM boxes: they asked protesters wear a mask beforehand explaining it reduces transmission, and had people at the protests handing out masks and showing people how to use it.

Quick detour as I sketch out what effective mask uptake would look like:
C - education on how to wear
O - handing out masks, education on how to make your own, special offers on cotton masks in shops
M - education on why- such as those pics of petri dishes, and incentives to wear

(examples of incentives could include skipping the queue for the shop if you're covering your face, establishing norms that wearing a mask is a socially conscious and cool thing to do, and so on)

Anyway, back on track, finally, let's look at adherence to staying home and how that changed.

Everyone still has the capacity to stay home
Everyone still has the opportunity to stay home
But motivation is muddied in mixed messaging and poor role models now.

A lot shifted with Cummings: if he can go on jollies to Durham, why can't anyone else go out? Why can't we go to the beach when the weather is nice? Cummings isn't the be all and end all of this problem, but a definite contribution to decreased motivation.

Other mixed messaging which is decreasing motivation to stay home as much as possible includes talk about how things are perfectly safe, such as going to non essential shops or going to a physical workplace unnecessarily. This builds complacency.

And actually, I lied when I said capacity and opportunity to stay home as much as possible is still present. That's not quite right as workplaces reopen and more in person work becomes required of many people.

It is going to take a LOT of work to get people back to not being silly about travelling around the country and not staying in, but to start, serving Cumming's head on a plate to send a message. And clear, consistent messaging is also really fuckin important.

tl;dr people don't know what the fuck they're meant to be doing, it's made difficult to do what they're meant to be doing, and they're not being given a reason to do the things which is why we're a bit fucked.

But after reading this thread, hopefully now as well as saying "the government has absolutely fucked it" you can also say "they fucked it by removing people's motivation to not just crowd on the beach"

OK fuck it, a couple more examples because I don't have much else to do this afternoon.

Isolating for 14 days when a contact has covid. Capability is there - you stay in your house, easy! Motivation is there - you might infect others. But the opportunity isn't always there.

Statutory sick pay when isolating is a pittance, you'll earn more going to work. And there's little guarantee of your job safety and your employer not being a dick if you do isolate - protections are poor and they might hit you for "absenteeism".

And even ability to access groceries is spotty; most people have eaten their pasta stockpile by now.

And so, to encourage isolation, government need to work on OPPORTUNITY. Enough money to live on without finances taking a hit, employment protections, food access!

(e.g. some countries send care packages of essentials for anyone isolating, supermarkets could do priority 24 hour delivery slots for people isolating, etc, to ensure access to essentials)

Now, one of the issues with government has been they tend to listen to marketing people rather than behavioural scientists. This means they're not bad at motivation-based awareness campaigns, but in general poor on building capability and TERRIBLE on opportunity.

That said, they're not exactly stellar at building motivation all the time, let's take a second to glare at Cummings again

Here's another one to look at: getting a test. Here, motivation is really high. People want a test, to find out if they have the disease. But capability and opportunity have a lot of room for improvement.

It's still hard to access a test, and not everyone who should be having one can get one. And self-swabbing is, as I understand it, really really fucking difficult to do with really really fucking complicated instructions. So, issues with opportunity and capability here!

As a sweeping generalisation of most coronavirus health behaviours, motivation is usually quite high - people want to do the right thing, and don't want to horrible death virus. But there's a lot of gaps in capability and opportunity to do them.

For the most part, interventions to increase capability would look like mass education campaigns, with clear, consistent, simple messaging about what to do and how.

And interventions to increase opportunity look a lot like socialism to address real material barriers to action.

Yeah, I'm sorry that science suggests socialism is a vital part of combatting coronavirus, but it kind of is, so there.

OK OK fine another one which I was musing on because on a short trip to the shops people were doing HORRIBLY: distancing. This one probably needs some research to prioritise which interventions but I suspect problems in C, O and M.

OPPORTUNITY to distance is difficult because of narrow pavements, aisles, etc.
CAPABILITY to distance is muddied by govt mixed messaging (one metre or two?) and absence of practical ways to judge if you're keeping distance properly.

And MOTIVATION to distance is a problem because desire to do the right thing seems to be massively outweighed by desire to walk two abreast or squeeze past someone to get to the broccoli five seconds earlier.

Interventions are possible on all fronts there, eg fun videos for tips for keeping distance; widening pavements; and really frowning upon people who can't patiently wait a few seconds to get at the dairylea

btw I am definitely sticking just to the real basics of the COM-B model in this thread because there are about a bajillion theories about the various subcomponents of capacity, motivation and opportunity, and how to change these bits and how they go together lol

But while we're here, shall we just do a little bit about how we can design interventions and measure and test all these things to see how we're doing? Because that's important, too.

So, first of all, you want to understand a bit about the behaviour, and why people are doing or not doing the thing. Questionnaires, observation, interviews, all that sort of thing. Get a holistic picture about beliefs, barriers and attitudes, all that shebang.

(ugh, SORRY, I used the preferred wording from like three different theories there. Let's make it easier and COM-B - get a holistic picture about whether people know how to do the thing, what's stopping them doing the thing or making it easier to do it, what they feel about it)

And so, now you know a bit about this thing. Really also worth asking people what they thing would make it easier to do the thing in your research, but I'm a huge fan of participatory research and that's not necessarily the norm.

So, what *can* we change? If you've identified the problem is motivation, time to target that and change it. And here's the kicker: if you've designed your intervention to change motivation, PLEASE MEASURE WHETHER THAT'S CHANGED to contribute to the body of evidence.

And obviously you also need to measure whether the behaviour has actually changed but PLEASE PLEASE PLEASE FOR THE LOVE OF GOD MEASURE IF THE VARIABLE YOU THOUGHT YOU WERE CHANGING HAS CHANGED

Behavioural scientist are good at this, local authorities and govt, not so much.

and marketing quacks are absolutely the worst at evaluating whether they've actually changed what they set out to change lol

ok mini rant over. So how do we measure behaviour change?

At a population level, it is very difficult and often unethical to measure whether behaviour has changed!! The gold standard, having one group receive the intervention and the other group not can be pretty unethical and definitely impractical.

But we can do "natural experiments" - for example, if a shop offers a discount to anyone wearing a mask, do customers who visit that shop wear a mask more often than people who don't visit that shop?

We can compare places where the rules are different - for example, were people travelling around less in Wales, where the advice was a clear, simple "stay local" giving an easier capacity not to travel, than England with the messy "stay alert"?

You can do before and after comparisons - for example, are people more likely to wash their hands properly after being bombarded with information about how to do it correctly (targeting capacity) than before they had this information?

What's very much necessary for understanding behaviour and adherence is monitoring - via observation and regular surveying - as to whether people are doing the things that they need to be doing, and throwing a lot of research into why they're doing it or not.

Fun thing: there's a massive infrastructure for market research already, which can easily be used to check in about what people are doing and why, and the government are very familiar with this infrastructure, so there's no excuse for not doing the research.

And also, there's a massive comms infrastructure which government have which could be used for capacity building interventions.

Oh, and massive infrastructure for making things happen, so opportunity based interventions are feasible.

That they're not is why they've fucked it.

Final thought (maybe. until I get all AND ANOTHER THING later, probably): we've established government have CAPABILITY and OPPORTUNITY to implement measures which can change population health behaviour. That they're not is probably due to MOTIVATION.

So, let's as a population do a little behaviour change intervention on the government by giving them the MOTIVATION to help us. Based on my research, the threat of them being overthrown or even massively hated is probably a good motivator.