Incorporating Nudges into COVID-19 Communication and Prevention Strategies

Author: Julia Rosenbaum, USAID WASHPaLS Project (FHI 360), March 31 2020 - Nudges are physical cues that influence people to behave in a certain way, without particular messaging or promotion of any behavior. Nudges avoid direct instruction, mandates or enforcement. The term "nudge" became popularized starting in 2008, after publication of Thaler and Sunstein's book by that name. Nudges engage audiences at a subliminal level and work 'reflexively', rather than providing information to audiences to 'reflect' upon and then act. Nudges are reflexive not reflective.

Nudge theory operates by designing elements or 'architecture' in the environment which encourage positive or improved behaviors. Nudge principles have been applied for social good as well as in commercial marketing. For example, when searching for a hotel room on priceline.com, the pop-up saying, 5 people are looking at this hotel right now! nudges browsers to not lose the opportunity and book now! At an airport or food court, bakeries intentionally emit sweet cinnamon scents to spur you to buy donuts or cinnamon buns. Nudging has also been successfully used for traffic safety, recycling and toilet etiquette.

In what has now become the iconic handwashing nudge example, cheerful footsteps in demarcated pathways led Bangladeshi school children from school latrines to handwashing stations brightly decorated with handprints. These nudges were found to be an effective way to nudge children to wash their hands after the toilet. Without additional handwashing education or motivational messages, handwashing with soap among school children increased from 4% at baseline to 68% the day after nudges were completed, and 74% at both 2 weeks and 6 weeks post intervention. (Dreibelbis et al, 2016). A second, larger trial showed nudges to be as effective as intensive health education without the intensive or expensive effort. (Grover, Hossain, Uddin, Venkatesh, Ram & Dreibelbis, 2018). The findings generated high interest in integrating nudges into behavior change programs; including, handwashing in health facilities (INudgeyou, 2016), schools (Thrive Networks, 2017), and communities.

While not explicit to nudge theory, easy access to any required supplies or equipment (called 'enabling technologies' because they remove obstacles to action) also facilitates the practice of behaviors. Linking nudges with access to flowing water and soap further facilitates behavior change, which is why nudges are often placed near handwashing stations with soap and water.

As we scramble to respond to the COVID-19 crisis, we suggest one effective approach, which is to incorporate nudges into COVID-19 communication and prevention strategies.

Key COVID-19 prevention strategies include:

• Frequent handwashing, including when returning home from trips outside;
• Avoid touching your nose, mouth, or eyes; and
• Social distancing by maintaining two meters or six feet apart.

Handwashing nudges have been elaborated and evaluated, primarily in school contexts. Footpaths, footprints, hands, and 'watching eyes' successfully nudge handwashing, as do mirrors (calling audiences to check their appearance in the glass). Again, placement of the nudges matters.

Nudges for other COVID-related prevention behaviors have not yet been defined, but collective brainstorming will help to develop possible nudges for different contexts.

As a start, we suggest nudges to spur social distancing might include painting six-foot rulers at the entrances to parks and markets. When walking or waiting in small groups, a two-meter (six foot) string or bright ribbon kept taut to assure the ideal distance is maintained. Others seeing the string - whether taut or flaccid - will be reminded to keep the safe distance from others.

There is some debate as to the effectiveness of various types of facemasks, particularly home-crafted masks, at protecting against aerosols that transmit coronavirus. Nonetheless, in addition to any partial protection offered by masks, the use of masks may nudge AWAY from bringing hands to your mouth or nose. Wearing one at the supermarket the other day, I stopped myself from wetting my finger to open a plastic produce bags (commonly used in US [United States] supermarkets). Gloves might also nudge 'hands off', however the effect could wear off as the wearer becomes more accustomed to the feel of the gloves.

As we enter into an unprecedented time, it is important to consider the use of nudges in our response strategies to assure swift and sustained preventive action.

Image credit: Kanika Campbell, from the March 31 2020 COVID-19 Webinar for SBCC Practitioners

Click here for the original blog as posted on the Global Handwashing Partnership website.

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