Wash and learn: change lessons from handwashing campaigns

27th May 2020

Throughout these strange and uncertain times, one piece of Government guidance has remained clear and emphatic: wash your hands. In the Prime Minister’s words: “Repetitive though it is, the best way we can help the NHS and ourselves is to wash our hands for twenty seconds, that’s two times ‘Happy Birthday’ or so I’m told, with hot water and soap. Wash your hands.” But how do you get an entire nation to change a habit? And what can we, as change managers, learn from it? 

The world is washing

Getting people to wash their hands is not just a domestic challenge: it is one of the most cost-effective ways to save lives globally. For example, improving hand hygiene can reduce rates of pneumonia – the deadliest communicable disease in the world – by more than 20%, and diarrhoeal diseases by roughly 40% (Aiello et al, 2008). Many campaigns over the years have tried to improve hand washing, but with mixed success. Handwashing is a task people should undertake very frequently: it is a habit. And there is ample evidence to show that is very difficult to change habits in a sustained way.

To tackle this challenge, handwashing campaigns are learning from behavioural psychology and neuroscience. The key insight is that there are two types of decision-making – and different areas of the brain – involved in handwashing, and campaigns need to target both if they are to succeed. The two types of thinking are set out in Daniel Kahneman’s totemic work ‘Thinking, Fast and Slow’ (Kahneman, 2011):

  • System 1 – or ‘reflexive’ thinking: rapid, automatic, instinctual, and emotional responses; performed by the ‘limbic system’ in the brain, within which the basal ganglia is specifically associated with habits; and
  • System 2 – or ‘reflective’ thinking: slow, deliberate, considered, analytical thinking which is ultimately quite tiring and effortful for us; undertaken by the neocortex, specifically the pre-frontal cortex which is responsible for strategic and long-term goal orientation.

Since System 2 thinking is effortful and tiring, System 1 ‘lightens the load’ by:

  1. sifting and filtering information, first using learned and instinctual patterns and biases (heuristics) to prioritise information and respond rapidly; and
  2. taking familiar actions and automating them – turning them into habits.

Creatures of habit

Traditionally, handwashing campaigns focussed on System 2 thinking: providing information and raising awareness (e.g. of germs, hygiene and the risks involved) to change people’s handwashing intentions.

Some more sophisticated campaigns have targeted System 1 responses by invoking emotions and working with heuristics to change people’s attitudes and intentions – as discussed in detail in our recent article Changing behaviours to save lives‘. One fantastic handwashing example of this is the SuperAmma (‘Super Mum’) campaign in Andhra Pradesh in India, which used the motivations of nurture, evoked disgust and used social norms (making it seem like everyone was doing it) to improve handwashing behaviours – watch a summary of the campaign here. Again, these interventions work to change people’s attitudes and intentions to wash their hands more and better (albeit at a more instinctual, System 1 level).

However, the evidence shows that even when these ‘awareness/intent’ campaigns are impactful:

  1. there is an ‘intention-behaviour gap’, i.e. people’s intentions are changed without necessarily changing their actual behaviours; and
  2. if behaviour does change, it is only for the short term.

As behavioural scientists Neal et al (2015a) concluded, awareness campaigns which target ‘intentions are generally effective at changing behaviors that people perform infrequently (e.g. blood donation) but are generally ineffective by themselves at changing habits (e.g. seatbelt use)’.

Principles for changing habits at scale

Based on this insight, campaigns are now deploying some fantastically innovative ‘habit strategies’ to target people’s fully automated habitual actions. This includes the recent UK Covid-19 handwashing campaign which was supported by the Behavioural Insights Team (previously part of the Cabinet Office). Below are some principles for changing habits, adapted from the great work of Neal et al (2015a and 2015b), as well as some example ingenious tactics deployed globally to disrupt bad handwashing habits and create new ones.

Principle 1) Ensure a supportive environment and provide reminders. The right facilities or products must be in place to trigger and support the habit consistently at the right times, and reminders can provide a further prompt. Some handwashing examples:

  • Brightly coloured sinks and footprint ‘paths’ (Nepal). Leading children from toilet to sink contributed to a rise in handwashing in schools from 9% to 65%.
  • Using a social robot called Pepe (Kerala, India). A little speaking hand-shaped robot with eye movement prompted children to wash hands. This incorporated the “Hawthorne Effect” (people change their behaviour when they know they are being watched) and caused a 40% rise in handwashing (Deshmukh et al, 2019).
  • Increasing hand sanitising (UK). In the UK, the focus was on increasing the number of hand sanitisers available wherever handwashing is not possible in the most impactful locations – e.g. at elevators where people usually have a momentary wait.

Principle 2) Piggyback on existing behaviours or context change. Rather than starting from nothing, try to tie the desired behaviour to existing actions or physical cues which are already part of people’s daily routines, environment or culture. Or try to land the new behaviour when people are going through major life shifts already and are open to change. Some handwashing examples:

  • Using mirrors (Kenya). People have an instinctive habit of looking in a mirror; incorporating mirrors into the Mrembo washstation in Kenya meant people checked the mirror and handwashing ‘came along for the ride.’
  • Singing happy birthday (UK). Getting people to sing happy birthday twice while washing is not just a mnemonic for judging 20 seconds – when someone starts to sing they are driven to complete the song and therefore the length of handwashing is ‘forcefully’ extended to match.
  • Building into existing habits (UK). UK posters have tried to link handwashing with other regular habits/activities – arriving home or at work, blowing your nose, or handling food; trying to create ‘if-then’ linkages.

Principle 3) Eliminate friction for new habit; add friction for the old. Even small amounts of effort, decision-making or extra steps can undermine a new behaviour and cause a relapse to old habits.

  • Pre-mixing soap solutions (Bangladesh). Teaching mothers to hang pre-prepared mixtures of soap and water in plastic bottles next to handwashing stations helped make the new behaviour as easy as possible (Neal et al, 2015a).
  • Downplaying face masks (UK). The effectiveness of face masks for the public is questionable, and they may even cause people to relax their wariness and therefore undermine the impetus for handwashing.

Principle 4) Encourage practice. Incentivising people to repeat a new behaviour enables them to build procedural memory.

  • ‘Surprise Soaps’ (Iraq). Families were given soap with a toy visibly embedded at their centre – meaning that repeated handwashing was required to receive the reward (Save the Children, 2018).
  • Bacteria-shaped handstamps (Chile). Abattoir workers were stamped each break, giving them a visible cue to handwash and placing social pressure on them to remove the mark (Groom and Vellacott, 2020).

It is important to note that these habit strategies do not replace the need to raise awareness and change people’s intentions – they need to be deployed together. This means targeting:

  • System 2 thinking – providing information for people to take rational decisions,
  • System 1 heuristics – ‘nudges’ to provide the right instinctive emotional responses, and
  • System 1 habitual responses – disrupting old and cuing new habits (as set out above).

These interventions all go hand in hand.

Now wash your hands

Not all the change programmes we work on will impact such frequent, habitual actions as handwashing – but many will. It could be getting people to work daily with new technology; or to follow a new process on a regular basis; or to identify themselves with a new mission or team. Or indeed the habit change you need to deliver may be in support of an executive, to help them to change their own behaviour in order to become a great change leader.

On my next programme I certainly plan to identify what future desired habits we want to see, and then put together a ‘habit strategy’ to make it happen. It seems like a good habit to get into.

 

By Tim Willott, CMC Consultant

 

References

Aiello, Coulborn, Perez and Larson, 2008. Effect of Hand Hygiene on Infectious Disease Risk in the Community Setting: A Meta-Analysis. Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2446461/>. Accessed April 2020.

Kahneman D, 2011. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux.

Neal, Vujcic, Hernandez and Wood, 2015a. The Science of Habit: Creating disruptive and sticky behavior change in handwashing behavior. Available at: <http://www.washplus.org/sites/default/files/resource_files/habits-neal2015.pdf>. Accessed April 202o.

Neal, Vujcic, Burns, Wood and Devine, 2015b. Nudging and Habit Change for Open Defecation. Available at: <http://documents.worldbank.org/curated/en/905011467990970572/pdf/104328-WP-PUBLIC-OD-Habit-and-Nudging-Catalyst-Behavioral-Sciences-022916.pdf>. Accessed April 2020.

Deshmukh, Babu, Unnikrishnan, Ramesh, Anitha and Bhavani, 2019. Influencing Hand-washing Behaviour with a Social Robot: HRI Study with School Children in Rural India. Available at: <https://www.psy.gla.ac.uk/~amold/papers/2019/Ro-Man-Hand_washing_Influence.pdf>. Accessed April 2020.

Global handwashing day: innovative ‘surprise soap’ gets children washing hands in emergencies, with lifesaving implications, 15 October 2018. Save the Children. Available at: <https://www.savethechildren.org.uk/news/media-centre/press-releases/global-handwashing-day–innovative–surprise-soap–gets-children>. Accessed April 2020.

Groom and Vellacott, 2020. Ripple: The big effects of small behaviour changes in business. Harriman House.