Behavioural Science Principles for Enhancing Adherence to Public Health Measures

The science of getting people to start something new is different from the science of getting them to continue positive behaviours. Amid rising rates of new SARS-CoV-2 variants of concern, Ontario needs a refreshed approach to maintaining and enhancing adherence to public health measures. Promising strategies to increase effective masking and physical distancing include persuasion, enablement, modelling the behaviour, and clear education.


Background
Effective COVID-19 vaccines signal hope that the pandemic may be drawing to an end, but Ontario is months away from fully vaccinating its population of about 15million individuals. Meanwhile, Ontario has entered a third wave of the pandemic with the rapid spread of more transmissible SARS-CoV-2 variants of concern (VOCs) which are both more transmissible and associated with more severe clinical outcomes. 1 Avoiding shared indoor spaces, physical distancing and wearing a mask remain the most important behaviours for Ontarians to protect themselves and those around them. Now more than a year into the pandemic, messaging and experience have helped to establish a variety of positive physical distancing and masking habits among Ontarians. There is an opportunity to capitalize on these existing behaviours to enhance and reinvigorate adherence to staying outdoors, physical distancing and masking. Increasing the number of people following these protective behaviours may curb the threat of VOCs and help Ontario enjoy a better summer.
Adherence to masking and distancing has become a habit for most Canadians, with 86% reporting wearing a face mask in public and 75% reporting following physical distancing guidelines. 2 While these successful behavioural changes should be recognized, these data also highlight an opportunity to support enhanced adherence to both physical distancing and masking. While 80% of Canadians report the ability to continue following these measures for at least the next six months, the majority are getting tired of following COVID-19 public health measures. 2 Capitalizing on existing habits while empathizing with fatigue requires a renewed and evidence-based approach to supporting public health measures that draws on behavioural science.

Understanding COVID-19 Fatigue
The pandemic has taken a toll on all Ontarians and some feel as though public health measures do not consider the unique impact these measures have on mental health and wellbeing. For example, focus groups conducted in early 2021 identified that young Ontarians (18-24 years of age) are overwhelmed by daily updates and

Behavioural Science Principles for Enhancing Adherence to Public Health Measures
confused about the provincial messaging regarding the colour-coded COVID-19 response framework. 3 While young adults reported "mostly" following public health measures, fatigue may lead to complacency towards measures as Ontarians actively juxtapose what COVID-19 has "taken away" from them against their risk of adverse consequences from contracting SARS-CoV-2 itself. 4

Questions
What behaviour change strategies can support maintaining already established behaviours?
What behaviour change strategies can support enhanced adherence to public health measures among those who don't realize they aren't complying?
Who is in a position to act on renewed strategies?

Findings
In this Science Brief, we focus on two key public health measures: physical distancing and masking. The tables below are intended to guide the reader by identifying barriers and selecting solutions with the following questions: "Which barriers do residents in my region face?" and "What strategies can we use to further support and enhance public adherence to public health measures?" In line with best practices in behavioural science, 5,6 we encourage the use of as many unique strategies as possible to maximize impact. Below, we present known barriers and behaviour change strategies that can each be used to address issues of capability, opportunity and motivation -the three key determinants of whether or not an individual behaviour is carried out. 7 Suggestions on how to operationalize theses strategies recognize that mitigating the severity of the COVID-19 pandemic requires the collaborative effort of public leaders, community leaders, healthcare organizations, and the general public. 8 As such, the strategies are explicitly linked to target groups in a position to action them to support two key groups of Ontarians: 1. Those who are already adhering to physical distancing and masking in most situations but are unclear on the remaining high-risk scenarios that exist in their lives (focus on maintenance).
2. Those who are inconsistently following these public health measures due to easily addressed capability, opportunity and motivation reasons (focus on enhancement).  16 Individual identity)

Tips for public and community leaders:
▪ Remind people what they could miss out on if not wearing a mask (e.g., trigger a fear of missing out with messages like -"Masking now helps deliver a better summer")

Modelling
Tips for public and community leaders: ▪ Use messaging from people we identify with helps embed an equity lens (i.e., those that look like me, have a similar job or life responsibilities, and do the things I do/want to do), with grassroots or community-based messaging often being most powerful Behavioural Science Principles for Enhancing Adherence to Public Health Measures Ontario COVID-19 Science Advisory Table   Findings Figure 1 summarizes evidence-based approaches to support Ontario organizations, including employers, professional associations, unions, and others in maximizing voluntary vaccination among Ontario's HCWs. These approaches draw from wellestablished behavioural science principles.

Interpretation
Governments, public health units, and healthcare organizations are delivering strategies to support Ontarians in adhering to public health measures, with an emphasis on physical distancing and masking. This Science Brief recognizes that more than a year into the COVID-19 pandemic, we need to move beyond "more of the same" when it comes to strategies to maintain and enhance how, when, and where Ontarians engage in masking and distancing. Groups in a position to support change can leverage behavioural science to refresh their approaches by using a range of evidence-based behavioural change strategies. These strategies can help to move beyond asking Ontarians to "do more" (potentially contributing to pandemicfatigue) and instead focus on creating the conditions needed to ensure ongoing adherence in our current state.

Methods Used for This Science Brief
The advice on this brief has been developed using the COM-B model. 9 COM-B is a theoretical framework employed by Behavioural Scientists to help identify key behavioural barriers to desired action. The model identifies three essential conditions: Capability, Opportunity, Motivation that affect Behaviour and decisionmaking. Capability barriers include lack of knowledge and comprehension about a behaviour and its consequences, and lack of skill necessary to carry out a behaviour. Opportunity barriers include time and resource constraints that make a desired behaviour more difficult or costly to carry out. Motivation barriers include emotional reactions and inaccurate beliefs that create obstacles for carrying out a behaviour.

Author Contributions
LD and JP conceived the Science Brief. LD wrote the first draft. All authors revised the Science Brief critically for important intellectual content and approved the final version.
Forgetting to bring or wear a mask (Environmental context; Available resources; Memory)

Environmental Restructuring
Tips for public and community leaders: ▪ Change things up with new signs in new places with increased salience so that they are noticed again ▪ Provide masks, prioritizing communities and settings where cost may be an issue ▪ Describe how to build prompts into one's personal environment (e.g., store masks near keys), keep a basket at the front door