A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic

Abstract

The coronavirus disease (COVID-19) pandemic has highlighted the link between individual behavior and public health, along with the importance of evidence-based efforts to promote prosocial individual behavior. Insights from behavioral science can inform the design of effective behavior change techniques, or nudges, to influence individual behavior. The MINDSPACE framework organizes 9 behavioral science principles that can be used to guide policy design: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments, and Ego. Using MINDSPACE as an organizing framework, this article provides a review of the literature on nudges to influence prosocial behaviors relevant during a pandemic: handwashing, avoidance of social gatherings, self-isolation and social distancing, and sharing public health messages. Additionally, empirical evidence on the use of nudges during the first several months of the COVID-19 pandemic in 2020 is summarized. Recommendations regarding the use of nudges to achieve public health policy goals during pandemics are provided. Organizational leaders, policymakers, and practitioners can use nudges to promote public health when mandates are not politically feasible or enforceable.

Introduction

The coronavirus disease (COVID-19) pandemic has highlighted the importance of behavioral science to guide individuals toward actions that benefit public health. Few scenarios demonstrate a more dramatic link between individual behavior and public health than pandemic disease, along with the importance of evidence-based efforts to promote prosocial behavior. The legality of mandates requiring prosocial behaviors such as mask wearing has been challenged throughout the first 2 years of the pandemic. For example, in April 2020, County Judge Lina Hidalgo issued an order requiring that residents of Harris County, Texas, engage in behaviors to promote public health, such as wearing a face mask while in public, with violators subject to a fine of up to $1000.

The order drew fervent backlash from members of the public, police officers concerned about enforceability,¹ and local leaders, one of whom filed a lawsuit to block implementation on the basis that Hidalgo lacked authority to “force private citizens to wear masks, wash their hands, refrain from touching their face, or stay 6 feet away from another under the threat of fines,”² highlighting the distinction between guidance and legally enforceable mandates.

Controlling the spread of an outbreak calls for large-scale, rapid, and substantial changes to individual behavior patterns to reduce mortality and health care system strain. Infectious disease is a classic example of negative health externalities, leading to market failures that can justify government intervention in the form of authoritative policies, or “shoves.”^3,4 However, as the case of the mask order demonstrates, mandating that individuals engage in certain behaviors may not be enforceable or politically feasible. Society must then rely on individuals' uptake of recommended behaviors to reduce the spread of disease. In such scenarios, there can be failings in the behavioral market that also justify governmental intervention.³

Thus, even in situations that warrant “shoves,” “nudges” that are based on behavioral science principles to motivate behavior change at the individual level can also be relevant.⁵ Nudges are behavior change techniques developed within the field of behavioral economics that represent a form of libertarian paternalism, preserving choice while guiding individuals toward behaviors with population-level benefits.⁶

In their book on the topic, Thaler and Sunstein defined a nudge as “any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives.”⁵ Organizational, state, and local policymakers and public health officials can incorporate nudges informed by behavioral science to create opportunities that simultaneously preserve individual choices and encourage prosocial behavior, potentially as complements to regulations and mandates.

Nudges have been used to inform public policy around the globe, garnering bipartisan support in the United States.⁷ They have been used to encourage public health and other prosocial behaviors, such as green energy use.^8,9 Throughout the COVID-19 pandemic, states, cities, and federal agencies have employed creative nudges to prompt people to adopt simple actions in the name of public health. Alabama enacted legislation urging fist bumps rather than handshakes.¹⁰ Boston used the number of iced coffees to help visualize 6 feet of distance.¹¹ The Occupational Safety and Health Administration now requires that businesses have alcohol-based hand sanitizers on hand.

To help categorize nudges based on underlying principles of behavioral economics and psychology, Ivo Vlaev and members of the Behavioral Insights Team from the United Kingdom's Cabinet Office, also referred to as the “Nudge Unit,” developed the MINDSPACE framework. MINDSPACE is an acronym developed from the names of several nudging mechanisms, which are largely automatic and contextual influences on behaviors: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments, and Ego.¹²

The Behavioral Insights Team aims to help the UK government develop and apply lessons from behavioral science to public policymaking. The MINDSPACE framework has been widely used to guide effective policy utilizing the latest insights from behavioral sciences and nudge theory,¹³ with researchers, government departments, and both public and private organizations using MINDSPACE as their guiding theoretical framework.

In a time when exercise of civil liberties must be carefully weighed against compelling public health interests, choice-preserving nudges can be employed to influence individual behaviors not amenable to regulation. Published literature provides evidence on the effectiveness of various mechanisms to increase uptake of behaviors that promote public health and social welfare.

In this article, literature is reviewed on nudges as behavior change techniques to promote the following prosocial behaviors: handwashing, avoidance of social gatherings, self-isolation and social distancing, and sharing public health messages. Using MINDSPACE as an organizing framework, this study describes what is known from the literature regarding public health emergencies and circumstances in which individual behavior impacts social welfare. Examples of nudges that were utilized in the early months of the COVID-19 pandemic are highlighted, and early empirical evidence on their support and effectiveness is summarized. Organizational leaders, policymakers, and practitioners can use nudges to promote public health when mandates are not politically feasible or enforceable.

Methods

Using the 9 MINDSPACE principles to guide search queries, a search was conducted for existing original peer-reviewed articles, manuscript preprints, and news articles using PubMed, Google Scholar, and Google News. Searches were designed to collect information on the use of nudges, both during public health crises and in general, to promote the following behaviors: handwashing, avoidance of social gatherings, self-isolation, and social distancing, and sharing public health messages. Original searches were conducted from April to May 2020.

A data abstraction form organized by principle was developed to facilitate abstraction of information about the intervention/recommendation, supporting references, question/problem, specific nudge outcome, behaviors addressed, key takeaways, ethical issues, and costs. Additionally, nudges utilized in US state-level policy were examined using resources available from the National Governor's Association, state government websites, and popular press outlets. Findings were narratively summarized according to the MINDSPACE principle.

Results

Information was abstracted from the literature related to 96 nudges. Descriptions of each principle and examples of their uses are displayed in Table 1. Findings related to each principle are summarized below.

Table 1.

Using the MINDSPACE Framework¹² to Identify Nudges to Promote Public Health During the Coronavirus Disease Pandemic

Principle/technique	What we know	Examples and emerging evidence on nudges during early stages of the COVID-19 pandemic
Messenger—we are heavily influenced by who communicates information. We are affected by the perceived authority of the messenger (whether formal or informal). Demographic and behavioral similarities between the expert and the recipient can improve the effectiveness of the intervention. We are also affected by the feelings we have for the messenger. We also, of course, use more rational and cognitive means to assess how convincing a messenger is.	• When sharing public health messages on social media, public health authorities and medical professionals are the most trusted messengers.⁷⁵ • Spread of information through individuals who are central in a social network, rather than random individuals, can lead to more behavior change.⁷⁶ • Transparent communication from a diverse set of experts, in whom the public has established trust and confidence before a pandemic occurs, can encourage adoption of recommended behavior.⁷⁷	• Health organizations and medical and public health professionals used Instagram and Twitter by to share public health messages.⁷⁸ • More than 75% of Americans reported trusting the CDC, compared with about 50% of Americans who trusted the news media, in early 2020.^15,16,79 • The CDC created a social media toolkit, including sample messages and accompanying graphics and videos bearing the CDC logo for Twitter, Facebook, Instagram, Pinterest, and LinkedIn.¹⁸ • At the end of 2019, the official CDC Twitter account (@CDCgov) had 1.2 million followers, which had increased to 2.6 million by April 20, 2020.¹⁷ • Marketing agencies' used use social media influencers to reach millennials to encourage avoidance of social gatherings.⁸⁰ • Twitter verified epidemiologists, issuing blue check marks to increase trust in individuals sharing public health messages.⁸¹ • Approximately 70% of Americans used some form of social media, the most common platform being Facebook,¹⁹ and quarantine led to an increase in social media usage, with a 27% increase in Facebook usage between January and April 2020.²⁰ • With the goal of promoting self-isolation, the majority of people responded positively to quarantine restrictions communicated by the government.⁸² • In Hong Kong, doctors were the most trusted sources to share public health messages.⁸³
Incentives—our evaluations of outcomes and responses to incentives are shaped by mental biases such as strongly avoiding losses (we dislike losses more than we like gains), reference points (the value of something depends on where we see it from), overweighting small probabilities (hence why lotteries may act as a powerful motivation), mental accounting (we tend to allocate different rewards/payoffs to discrete mental accounts), and present bias (we prefer more immediate rewards).	• To promote self-isolation, lower the cost of staying home or increase the cost of going out; perceptions of risk to self and others are associated with self-isolation compliance.⁸⁴ • To encourage avoidance of social gatherings, “gentle reinforcement” programs that involve unpleasant experiences, such as reminders from supervisors and written violations, are associated with failure to comply with protocols can increase adherence to safety protocols.⁸⁵ • To promote self-isolation, perceptions of risk are associated with quarantine compliance.⁸⁴	• New takeout offerings, such as allowing sale of alcoholic beverages to-go, can decrease the cost of self-isolation.⁸⁶ Eight states announced temporary changes to liquor policies to allow sale of liquor-to-go and/or alcohol delivery; before the changes, only 12 and 31 states allowed direct-to-home shipping and alcohol delivery, respectively.⁸⁷ • The Families First Coronavirus Response Act enacted in mid-March 2020 required certain employers to provide paid sick leave to eligible employees affected by the crisis.²³ A few states (CO, NY, NC) have temporarily broadened access to paid sick leave as well.¹⁰ • Measures adopted by several state legislatures requested funding for rental assistance (AL), temporarily halting foreclosures and evictions (MA).¹⁰ • 42 States, Washington, DC, and Puerto Rico imposed stay-at-home orders; of those, 31 had fines ($100–$25,000, median $1000) and 26 included jail time (1–18 months, average 6.9) as possible penalties.²⁵ • When individuals assume that they will be compensated for lost wages, they are more likely to comply with self-isolation recommendations.⁸⁸ • Other interesting “carrots” to encourage social isolation by lowering cost of staying home (by eliminating boredom) included governments subsidizing impactful home-based work, the provision of free online courses, or access to web-streamed entertainment services.^27,28
Norms—we are strongly influenced by what others do. Social and cultural norms are the behavioral expectations, or rules, within a society or group. Norms can be explicitly stated or implicit in observed behavior. People often take their understanding of social norms from the behavior of others. Relate the norm to your target audience as much as possible and consider social networks.	• Making hand hygiene and avoiding social gatherings the norm can increase favorable behavior.⁸⁹	• Social media allows individuals to see others in their own social networks avoiding social gatherings or engaging in hand hygiene, which may create norms in their own social group.⁹⁰ • Statewide closure of non-essential business spaces (42 all required/10 some required/3 guidance) made a new norm of working from home. • Behavioral norms around response to COVID-19 were shaped by main media source.⁶⁷ • Americans reported new norms about avoiding crowds and public transport.³⁰ • AR and IA officially banned groups of 10 or more; there are statewide school closures in all states; Domestic Travel Limitations by Executive Order in 22 states, with recommendations in 12 additional states.⁹¹ • Instagram users could add a “Stay Home” sticker to any of their Instagram stories, creating a culturally relevant norm within social circles and among followers of staying at home.³¹ • Snapchat implemented a prosocial behavior lens and stickers which users could attach to any of their Snapchat stories to be viewed by followers, creating prosocial norms within social group.³²
Defaults—we “go with the flow” of preset options. Many decisions we make every day have a default option, whether we recognize it or not. Defaults are the options that are preselected if an individual does not make an active choice. Defaults exert influence as individuals regularly accept whatever the default setting is, even if it has significant consequences.	• Strategic placement of hand sanitizer stations and soap dispensers can encourage hand hygiene.^92,93	• Infectious disease experts called for elimination of handshake greetings as defaults to promote hand hygiene.^94,95 AL enacted legislation to encourage fist bumps instead of handshakes to reduce the frequency of need for handwashing.¹⁰ The popular press recommended “alternative handshake” or alternative ways to greet people instead of a handshake to avoid contamination.³⁷ • Companies required or encouraged workers to use video conference calls or phone calls (as new defaults) instead of face-to-face meetings.³⁴ • Individuals defaulted to purchasing groceries online instead of in-person at the grocery store.³⁸ • Employer work-at-home orders nudged the default of staying at home.³⁵ • Dating websites introduced new app features to allow for virtual happy hours and hotlines to dating experts to increase the likelihood that individuals socially distance and chat using the app as opposed to meeting in-person.³⁶
Salience—our attention is drawn to what is novel and seems relevant to us. Our behavior is greatly influenced by what our attention is drawn to. People are more likely to register stimuli that are novel (messages in flashing lights), accessible (items on sale next to checkouts), simple (a snappy slogan), and relevant (easier to grab attention at moments when people enter a new situation or life stage such as moving house, going to university, pregnancy, etc.). We also look for a prominent “anchor” (such as unusual or extreme experiences, price, and advice) on which to base our decisions.	• Using Instagram stories (video) to share public health messages can engage diverse audiences and make them stick in memory.⁹⁶	• A graphic depicting how to “flatten the curve” of pandemic spread and #flattenthecurve were viral on social media, encouraging self-isolation and social distancing. ⁹⁷ Since first being shared on March 8, 2020, 1 iteration of this graphic made 4.5 million impressions on Twitter, including more than 12,700 retweets by the end of the next month.³⁹ It has also been shown on broadcast media, and 71% of Americans have seen or heard about flattening the curve, with 56% agreeing with the concept as of March 2020.⁴⁰ • CDC social media toolkit included short videos that were easily shareable to numerous social media platforms.¹⁸ • City of Boston translated 6 feet into the number of iced coffees to make the recommended distance to maintain from others' salient to the local population.¹¹ Similarly, A City of Round Rock meme recommending washing your hands like you just chopped some jalapenos and need to take your contacts out has been shared up to 3 million times; for lots of Texans that have made the mistake of touching their faces after slicing jalapenos, this is a vivid reminder.⁴¹
Priming—our acts are often subconsciously influenced by situational cues that activate (prime) information in our memory. People's subsequent behavior may be altered if they are first exposed to certain sights, words, or sensations (ie, behave differently if they have been “primed” by certain cues beforehand). Priming often activates a goal, which affects information processing, resulting in people attempting to achieve the primed goal representation (ie, situational cues can prime goal-directed behaviors without the need for conscious intentions or awareness).	• Guiding feet to sink after using the toilet can encourage good hand hygiene.⁹⁸ • Among health professionals and visitors in a surgical intensive care unit, exposures to a clean, citrus smell and to a picture of male eyes (but not female eyes) placed over the hand gel dispenser were associated with significantly higher levels of hand hygiene compliance and alcohol-based hand sanitizer use.⁹⁹	• At grocery stores, placing brightly colored tape lines on the floor 6 feet apart in cashier lines or in queues outside of stores was intended to encourage social distancing.¹⁰⁰ The City of Austin and LA County required social distancing in stores using tape lines.^45,46 The requirements also included providing employees and customers with sanitizers and placing these in conspicuous areas. • The UK government developed a new handwashing poster that explicitly linked handwashing with 3 regular activities: getting home or to work, blowing your nose, and eating or handling food.³³ • Costco prevented returns on certain items and posted signs to prime customers to avoid purchasing more than they need.⁴⁸ • The Occupational Safety and Health Administration issued COVID-related guidelines, which included providing and encouraging the use of tissues, no-touch trash cans, hand soap, alcohol-based hand rubs containing at least 60% alcohol, requiring handwashing and posting handwashing signs in restrooms.⁴⁷
Affect—our emotional associations can powerfully shape our actions. Emotional responses to words, images, and events can be very rapid and automatic. Moods, rather than deliberate decisions, can therefore influence judgments. People in good moods make unrealistically optimistic judgments, while those in bad moods make unrealistically pessimistic judgments.	• Social media posts that make positive emotional appeals or provide factual information attract higher levels of user engagement when sharing public health messages.¹⁰¹	• “Social distancing” was rebranded as “physical distancing” to encourage self-isolation and social distancing while encouraging people to stay connected and mitigate negative psychological responses to isolation.⁵⁰ • Inducing empathy for those most vulnerable to the virus encouraged self-isolation and social distancing.¹⁰²
Commitments—we seek to be consistent with our public promises, and to reciprocate acts. People use commitment devices to achieve long-term goals. It has been shown that commitments usually become more effective as the costs for failure increase. One common commitment device for increasing such costs is to make commitments public since breaking the commitment will lead to significant reputational damage. Even the very act of writing a commitment can increase the likelihood of it being fulfilled. Creating an action plan which specifies who needs to do what, when, and where is also a commitment device. A final aspect of commitment is our strong instinct for reciprocity, which is linked to a desire for fairness.	• Use of Facebook profile frames is associated with actual behavior.⁵² • Making precommitments is associated with greater follow-up on intended actions, including health behaviors.^103,104	• Facebook users could add a “Stay At Home” frame to their profile photo to encourage self-isolation.⁵³ • Individuals could take online pledges to commit to proper public health behaviors during the pandemic, including a pledge to #StandAgainstCorona and a pledge stating “As a Global Citizen, I'm Staying Home!”^54,55
Ego—we act in ways that make us feel better about ourselves. We tend to behave in a way that supports the impression of a positive and consistent self-image. We think the same way for groups that we identify with. We also like to think of ourselves as self-consistent. When our behavior and our self-beliefs are in conflict, often it is our beliefs that get adjusted, rather than our behavior.	• In public health crises, individuals can exhibit community-mindedness and sense of duty not to infect others by practicing social distancing.¹⁰⁵	• Deontological messages that emphasize protection of others (eg, “others” are more likely to get sick) were most impactful among messaging types to encourage intention of self-isolation and social distancing.⁵⁶ • Individuals perceived COVID-19 as a more serious threat when messages highlighted risks to younger adults, in addition to risks to older adults, which may encourage recommended actions such as self-isolation and social distancing.⁵⁸ • For men, who on average believe that they are less likely to become sick due to coronavirus and are less compliant with prosocial health behaviors, tailored messages could include framing masculinity as protecting one's family through the adoption of prosocial behavior.⁶² • Gamification of social distancing via location-tracking leaderboards by Snapchat-owned Zenly allowed others to view individuals' “stats,” demonstrating commitment to proper isolation.⁶¹ • “Six Feet Saves” was a social media campaign that encouraged social distancing to protect yourself and your loved ones.⁵⁹

AL, Alabama; AR, Arkansas; CDC, Centers for Disease Control and Prevention; CO, Colorado; COVID-19, coronavirus disease; IA, Iowa; LA, Los Angeles; MA, Massachusetts; NC, North Carolina; NY, New York.

Nudges to promote public health

M—Messenger

Who communicates information matters, especially in terms of the perceived authority of the messenger.^12,13 In general, public health authorities and medical professionals are the most trusted messengers during a public health emergency. In the spring of 2020, Pew Research Center poll data suggested 74% of US adults had a mostly positive view of medical doctors overall.¹⁴ Similarly, the vast majority of Americans had a favorable view of the Centers for Disease Control and Prevention (CDC; 79%) and the Department of Health and Human Services (HHS; 80%), with no significant difference along political party lines.¹⁵ In comparison, only 51% of Americans reported trusting the news media.¹⁶

The presence of organizations such as the CDC on social media can extend the reach of messages and provide a trusted and recognized source to counter the spread of false information online. At the end of 2019, the official CDC Twitter account (@CDCgov) had 1.2 million followers, which had increased to 2.6 million by April 20, 2020.¹⁷ The CDC created a COVID-19 social media toolkit, including sample messages and accompanying graphics and videos bearing the CDC logo for Twitter, Facebook, Instagram, Pinterest, and LinkedIn.¹⁸ Americans are likely to engage with such messages, as approximately 70% of Americans use some form of social media, the most common platform being Facebook.¹⁹ Moreover, stay-at-home orders led to an increase in time spent on social media, with a 27% increase in Facebook usage between January and April 2020.²⁰

I—Incentives

Mental biases influence how individuals evaluate potential outcomes, including avoidance of losses, overweighting small probabilities, and present bias (preferring more immediate rewards).¹³ The intuition behind incentives during a pandemic is that interventions that increase the cost of activities that are high-transmission risk (eg, instituting penalties), decrease the benefit of doing these activities (eg, bans on large gatherings, closure of entertainment venues), or decrease the cost of not doing them (eg, alcohol and food takeout, paid sick leave, freezing evictions and utility shutoffs) will encourage proper social isolation.

For example, 8 states announced temporary relaxation of liquor laws and regulations to allow bars and restaurants to sell liquor to-go and/or offer home delivery in the early months of 2020. Before these changes, just 12 states allowed alcohol delivery and 31 allowed direct-to-home shipping of beer/wine.^21,22

Paid sick leave makes it less costly to self-quarantine if sick. The Families First Coronavirus Response Act, signed into law in March 2020, required certain employers to provide paid sick leave to eligible employees who are sick, need to quarantine or self-isolate, care for a sick or quarantined family member, or care for a child whose school has been closed.²³ State legislatures also enacted policies in response to the pandemic regarding paid sick leave, rental assistance, and temporary freezes on foreclosures, evictions, mortgages, and utility shutoffs.¹⁰ These interventions aimed to promote housing and financial security during the crisis to defray the cost of staying home.

On March 15, 2020, the CDC released guidelines recommending cancellation or postponement of in-person events with 50 or more people.²⁴ These guidelines rendered socializing and leaving the house relatively less appealing. Additionally, 42 states along with Washington, DC and Puerto Rico issued “shelter-in-place” orders as of May 2020. While governors of 3 additional states (Oklahoma, Utah, Wyoming) had not mandated quarantine, individual counties or cities across these states had.

Of the 44 stay-at-home orders, 31 imposed fines ranging from $100 to $25,000 (median $1000) and 26 threatened jail time ranging from 1 to 18 months for violators. Most governors explicitly noted that they did not plan to aggressively enforce these penalties except for egregious or repeat offenses. These orders, therefore, represented “strong suggestions” intended to nudge citizens into staying home due to a potential financial or judicial penalty.^25,26

Two lead economists at the World Bank proposed “carrots” that governments could use to incentivize staying at home. These include subsidizing the following: useful home-based activities such as data labeling or document digitization, human capital development in the form of online courses, and entertainment through web-based streaming services.²⁷ Regarding subsidized education, the Australian government offered discounted online courses targeting areas of national demand as part of a coronavirus relief package.²⁸

N—Norms

Individuals are strongly influenced by what others do, which shape the social and cultural norms in a society or social network.^12,13 Moderate social distancing for 3–4 months beginning in March 2020 was projected to save 1.7 million lives by October 1, corresponding to economic benefits from reduced mortality worth about $8 trillion, or $60,000 per US household, when applying the US government's value of a statistical life.²⁹

Such social distancing, however, required establishment of new norms. For example, Americans reported adopting new norms regarding crowds and public transport, with 89% reporting avoidance of public transportation such as planes, buses, subways, or trains in a March 2020 Gallup poll.³⁰ Arkansas and Iowa officially banned groups of 10 or more; there were statewide school closures in all states, and limitations on domestic travel by Executive Order in 22 states, with recommendations in 12 additional states.¹⁰

Social media can also promote social distancing as a new norm within social circles. Instagram users were able to add a “Stay Home” sticker to any of their stories, demonstrating their support for staying home to their social networks.³¹ Snapchat also introduced filters and stickers promoting various prosocial behaviors such as washing hands, staying home, physical distancing, and avoiding face touching.³²

There has been widespread public shaming online of individuals who deviate from prosocial COVID-19 norms. In addition, public shaming of companies' decisions to stay open against norms, including Waterstones and Sports Direct, led to reversal of their policies.³³

D—Defaults

In many situations, individuals rely on default options, the options that are preselected if an individual does not make an active choice.^12,13 To encourage social distancing, video conferences (such as Skype, Zoom, Microsoft Teams) or phone calls replaced face-to-face meetings as the new default.³⁴ Employer work-from-home policies made telecommuting the new status quo, with 25%–30% of the US workforce predicted to be working remotely 1 or more days per week by the end of 2021, compared with less than 4% working from home half-time or more in early 2020.³⁵

Similarly, dating apps added video chat capabilities and introduced new features such as virtual happy hours to default to a new form of virtual dating, at least early in relationships. Some apps reported that conversation volume increased by 20%–30%, suggesting that people defaulted to video chatting and online dating, which some experts suggest could be a permanent switch.³⁶

A former staple of the boardroom, the handshake may also give way to a new default greeting in efforts to reduce the need for handwashing. Alabama enacted legislation urging all individuals to fist bump rather than shake hands.¹⁰ Similarly, creative alternatives to handshakes were proposed in the popular press.³⁷ The increased popularity of online grocery purchase, a new potential default option in lieu of in-person shopping at grocery stores, represents an additional example of potential new defaults.³⁸

S—Salience

Individuals' behaviors are influenced by what draws attention and seems relevant.^12,13 One image to promote the salience of engaging in social distancing and handwashing behaviors showed the impact of such nonpharmaceutical interventions for slowing the spread of COVID-19 and helped visualize what it means to “flatten the curve,” which quickly became a household phrase. Since first being shared on March 8, 2020, 1 iteration of this graphic made 4.5 million impressions on Twitter, including more than 12,700 retweets by the end of the next month.³⁹ It was also shown on broadcast media, and 71% of Americans reported having seen or heard about flattening the curve, with 56% agreeing with the premise, according to a March 2020 Civic Science poll.⁴⁰

Appeals to local culture also increased the salience of messages. A city of Round Rock meme that reminded Texans to “Wash your hands like you just got done slicing jalapeños for a batch of nachos and you need to take your contacts out” was shared 3 million times as a vivid and regionally specific reminder to scrub for 20 seconds.⁴¹ Similarly, the City of Boston translated the 6 feet social distancing recommendation into the number of iced coffees that would need to be lined up in a row to reach the recommended distance, salient to the local population.¹¹

As the pandemic worsened, 74% of Americans reported being “very” or “somewhat worried” that they or a family member will be exposed to the coronavirus by beginning of April 2020 according to Gallup polling data.⁴² Impacts associated with a shuttered economy, such as job loss, appeared to increase salience of the pandemic among some population groups, as Pew poll data suggest that 33% of individuals with low incomes experienced high distress versus only 17% of those with high incomes.⁴³

P—Priming

Individuals are often subconsciously influenced by situational cues that activate, or prime, information in their memory.^12,13 Priming prosocial behavior, such as social distancing, can be achieved through visual aids. For example, brightly colored tape lines on the floor in grocery stores were placed to help people maintain distance between other shoppers. Local government orders in San Francisco, California and Austin, Texas required social distancing in stores using methods such as tape lines.^44,45 An order for social distancing in stores was also in place in Los Angeles County, along with a requirement for stores to provide easy access to alcohol-based hand sanitizers.⁴⁶

To promote handwashing, the Occupational Safety and Health Administration released a set of guidelines requiring businesses to have alcohol-based hand sanitizers during the pandemic, the mere presence of which is linked to increased hand hygiene behaviors.⁴⁷ Stores such as Costco created store policies to prevent returns on items such as toilet paper and sanitizing wipes,⁴⁸ priming shoppers to buy fewer units of these items which were commonly in short supply. The UK government designed a poster linking handwashing to regular daily tasks in an effort to prime formation of a new handwashing habit.

A—Affect

Emotional associations can powerfully shape individuals' actions, with good moods leading to unrealistically optimistic judgments and bad moods leading to unrealistically pessimistic judgments.^12,13 An increasing number of Americans, approximately 37% by mid-April 2020, reported feeling less connected in Gallup polls.⁴⁹ One nudge to encourage connection while staying physically separated was rebranding the phrase “social distancing” as “physical distancing.”⁵⁰ Physical distancing became the recommended terminology for use by policymakers and other public officials to promote social solidarity and virtual interaction while maintaining physical distance.⁵¹

C—Commitments

Commitment devices can help achievement of long-term goals, as individuals seek to be consistent with public promises, and commitment is linked to reciprocity through a desire for fairness.^12,13 Commitment devices that promote social distancing included several social media campaigns in the early months of the pandemic. Facebook profile frames have been shown to promote fidelity to the advertised topic.⁵² Facebook users could add a “Stay At Home” frame to their profile photo to encourage self-isolation.⁵³ As of April 30, 2020, more than 2600 people had taken the pledge to #StandAgainstCorona online, publicly committing to wash hands, cover coughs, keep distance, and care for others.⁵⁴ Similarly, more than 124,000 people had taken the following online pledge: “As a Global Citizen, I'm Staying Home!”⁵⁵

E—Ego

Individuals tend to behave in ways that support the impression of a positive and consistent self-image.^12,13 When our behavior and self-beliefs conflict, nudges that rely on the ego mechanism encourage changes in behavior rather than beliefs. Messages that emphasize protection of others (eg, “others” are more likely to get sick) and deontological messages (duties to protect others) can motivate behavior change.⁵⁶

While data from Pew polling suggested that younger Americans viewed COVID-19 as a bigger threat to finances than health,⁵⁷ individuals perceived COVID-19 as a more serious threat when messages highlighted risks to younger adults in addition to older adults, which may inspire recommended actions such as self-isolation and social distancing.⁵⁸ “Six Feet Saves,” a social media campaign developed by Monroe County and the City of Rochester, New York, encouraged social distancing to protect yourself and your loved ones.^59,60

In an appeal to ego through gamification, a location-tracker app called Zenly launched a stay-at-home leaderboard, which individuals could share to various social media accounts to show friends and followers how well they were doing at socially distancing and staying home.⁶¹ For men, who on average believed that they were less likely to become sick due to coronavirus and were less compliant with prosocial health behaviors, tailored messaging could include framing protection of one's family and community via adoption of prosocial behavior as a masculine habit.⁶²

Factors associated with efficacy of public health-promoting nudges

Insights from behavioral analyses during previous pandemics can inform design of specific nudge mechanisms. For example, during the 2009 H1N1 flu pandemic, adoption of protective behaviors such as self-quarantine, mask wearing, and handwashing was associated with individual characteristics—being older in age, female, more educated, and a race or ethnicity other than White.⁶³

Additionally, individuals' political affiliation is consistently associated with perceptions of public health and threat of pandemic disease.^64
–66 Based on data from early stages of the pandemic, these associations held true in the context of COVID-19. Data from a mid-March 2020 Pew poll showed that Americans' knowledge and understanding of the COVID-19 pandemic and perceived appropriateness of media coverage differed by main source for political news.⁶⁷

News source was strongly correlated with political affiliation, with the majority (76%) of those who mainly viewed Fox News identify as conservative Republicans and Republican leaning, while Democrats and Democratic leaners made up most (57%) of MSNBCs primary viewership.⁶⁷ Precautionary behavior changes and threat perceptions of the coronavirus measured in an NPR/PBS NewsHour/Marist Poll also from mid-March 2020 showed that a majority of Republicans (54%) perceived the threat as overblown, while the majority of Democrats (76%) considered it a legitimate threat.⁶⁸

In a US county-level analysis of vote share in the 2016 presidential election and COVID-19 risk perceptions, support of President Trump in a county was also associated with lower risk perceptions, as measured by searches for information on the virus and social distancing behavior assessed using cell phone location data.⁶⁹ A greater proportion of Trump voters was associated with fewer individuals searching for information on the virus and less social distancing, even after school closure and work-from-home orders took effect. These trends only reversed following White House issuance of social distancing guidelines and exposure of conservative politicians to the virus.⁶⁹ Moreover, states with Republican governors and governors from states with more Trump supporters were slower to adopt social distancing policies.⁷⁰

In addition to political leanings, other individual attitudes have also been associated with uptake of prosocial behaviors. The theory of planned behavior may provide a useful conceptual framework for analysis of individuals' compliance with public health guidelines during a pandemic. In an analysis of compliance with self-isolation, attitude was the strongest predictor of compliance with self-isolation, while subjective norms and perceived behavioral control also had a significant influence.⁷¹ During the first week of the COVID-19 outbreak in the United States, perception of likelihood of personal infection was the strongest predictor of engagement in prosocial behaviors, such as social distancing and handwashing, compared with likelihood of transmission or severity of potential transmitted infections.⁷²

There was also evidence of optimism bias. In a survey of individuals in the United States, the United Kingdom, and Germany, respondents underestimated the risk of getting infected with COVID-19 and of infecting others (relative to someone similar to them infecting others).⁷³ The more optimistic individuals were about not infecting others, the less likely they were to think social distancing is necessary, practice social distancing, and follow handwashing guidelines. Among teenagers, attitudes about COVID-19 severity, social responsibility values, social trust, and self-interest were associated with news monitoring, social distancing, and disinfecting behaviors.⁷⁴

Discussion

While authoritative policies such as mandates and bans enacted in the wake of the COVID-19 crisis have garnered much backlash, evidence from previous outbreaks of viral disease and early experience with the COVID-19 pandemic suggests that policymakers can employ nudges to encourage compliance with public health-promoting behaviors, such as handwashing and social distancing. Medical doctors and public health officials are highly trusted messengers by members of the public across the spectrum of political orientation.

Policymakers should involve physicians, public health experts, and science communicators when communicating with the public about recommended behaviors. Messages that emphasize the ability of anyone to become ill regardless of age and that highlight physicians' experience of caring for critically ill patients may have the greatest chance of being impactful and potentially encouraging behavior change in the widest range of individuals.

Footnotes

Authors' Contributions

H.S.S., J.S.B.-B., and I.V. conceptualized and designed the study, reviewed and revised the article, and approved the final article as submitted. H.S.S. drafted and revised the article. R.C., O.H., A.H., and R.K. coordinated the review and the data collection, critically reviewed the article, and approved the final article as submitted.

Disclaimer

The views expressed are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

Author Disclosure Statement

The authors declare no conflict of interest.

Funding Information

Prof. Ivo Vlaev was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands.

References

Despart

. Hidalgo orders Harris

County residents to wear masks in public

, draws fire from police unions

GOP

. Houston

Chronicle

. April 22, 2020. https://www.houstonchronicle.com/news/houston-texas/houston/article/harris-county-mandatory-mask-order-coronavirus-15217911.php Accessed April 29, 2020 .

Judge Denies Hotze's Mask Order

TRO

. 2020. https://www.harriscountycao.org/press-releases/2020/4/27/judge-denies-hotzes-mask-order-tro Accessed April 29, 2020 .

Sunstein

CR.

Nudges vs. shoves. Harv L Rev F, 2013; 127:210.

Gostin

, Wiley

. Governmental Public Health Powers during the COVID-19 pandemic: stay-at-home orders, business closures, and travel restrictions. JAMA, 2020; 323:2137–2138.

Thaler

, Sunstein

. Nudge: improving decisions about health, wealth, and happiness. Penguin, London, 2009.

Sunstein

CR.

Why nudge?: the politics of libertarian paternalism. Yale University Press, New Haven, 2014.

Sunstein

. People Like

Government “Nudges

, ” Study

Says

. Scientific

American

. 2017. October 12, 2017. https://www.scientificamerican.com/article/people-like-government-ldquo-nudges-rdquo-study-says/?print=true Accessed January 7, 2021 .

Berger

. The power of the nudge to change our energy future. Scientific

American

. 2015; 2020. January 7, 2021. https://www.scientificamerican.com/article/the-power-of-the-nudge-to-change-our-energy-future/ Accessed December 29, 2015 .

Blumenthal-Barby

, Burroughs

. Seeking better health care outcomes: the ethics of using the “nudge.”. Am J Bioeth, 2012; 12:1–10.

10.

State Action on Coronavirus (COVID-19). Updated April 28, 2020. https://www.ncsl.org/research/health/state-action-on-coronavirus-covid-19.aspx Accessed April 29, 2020 .

11.

@CityOfBoston. If you're having trouble figuring out what 6 feet looks like between you and someone else, here's a familiar way to picture it Rain, snow, or shine, we love our #icedcoffee in this town #PhysicalDistancing #SocialDistancing. April 19, 2020.

12.

Dolan

, Hallsworth

, Halpern

, King

, Metcalfe

, Vlaev

. Influencing behaviour: the mindspace way. J Econ Psychol, 2012; 33:264–277.

13.

Vlaev

, King

, Dolan

, Darzi

. The theory and practice of “nudging”: changing health behaviors. Public Adm Rev, 2016; 76:550–561.

14.

Funk

CaG

, John. Amid coronavirus threat

Americans generally have a high level of trust in medical doctors

. Updated March 13, 2020. https://www.pewresearch.org/fact-tank/2020/03/13/amid-coronavirus-threat-americans-generally-have-a-high-level-of-trust-in-medical-doctors/ Accessed April 29, 2020

15.

Rainie LaP, Andrew. The state of Americans' trust in each other amid the COVID-19 pandemic. Pew Research Center. April 29, 2020. Updated April 6, 2020. https://www.pewresearch.org/fact-tank/2020/04/06/the-state-of-americans-trust-in-each-other-amid-the-covid-19-pandemic/ Accessed April 29, 2020 .

16.

Piacenza

. News media credibility rating falls to a new low. Updated April 22, 2020. https://morningconsult.com/2020/04/22/media-credibility-cable-news-poll/ Accessed April 29, 2020 .

17.

CDC. Twitter. 2020. Updated January 10, 2020. https://www.cdc.gov/metrics/socialmedia/micro-blogs.html Accessed April 29, 2020 .

18.

CDC. Social Media

Toolkit

. Updated April 20, 2020. https://www.cdc.gov/coronavirus/2019-ncov/communication/social-media-toolkit.html Accessed April 29, 2020 .

19.

Social Media Fact

Sheet

. Updated June 12, 2019. https://www.pewresearch.org/internet/fact-sheet/social-media/ Accessed April 29, 2020 .

20.

Koeze

, Popper

. The virus changed the way we

Internet

. The New York

Times

. April 7, 2020. https://www.nytimes.com/interactive/2020/04/07/technology/coronavirus-internet-use.html Accessed February 2, 2022 .

21.

Leasca

. These states are now letting people order alcohol to-go. Updated April 29, 2020. https://www.travelandleisure.com/food-drink/these-9-states-now-let-people-order-alcohol-to-go Accessed February 2, 2022 .

22.

Pershan

Liquor laws loosen up in the face of delivery-only dining. Updated March 20, 2020. https://www.eater.com/2020/3/20/21188482/state-liquor-laws-loosen-to-allow-takeout-alcohol-during-coronavirus-pandemic Accessed April 29, 2020 ,

23.

Families First Coronavirus Response Act: employer paid leave requirements. https://www.dol.gov/agencies/whd/pandemic/ffcra-employer-paid-leave Accessed February 2, 2022 .

24.

CDC. Resources for Large Community Events & Mass

Gatherings

. Updated March 15, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/large-events/index_2.html Accessed April 29, 2020 .

25.

See which states and cities have told residents to stay at home. The New York Times.https://www.nytimes.com/interactive/2020/us/coronavirus-stay-at-home-order.html Accessed April 29, 2020 .

26.

From a $25,000 fine to a warning: how are states enforcing the coronavirus stay-at-home orders? Updated April 4, 2020. https://www.kake.com/story/41973801/from-a-25000-fine-to-a-warning-how-are-states-enforcing-the-coronavirus-stay-at-home-orders Accessed April 29, 2020 .

27.

Sanghi

, Lokshin

. Can public policy incentivize staying at home during COVID-19? . April 23, 2020. https://www.brookings.edu/blog/future-development/2020/04/23/can-public-policy-incentivize-staying-at-home-during-covid-19/ Accessed February 2, 2022 .

28.

Duffy

. The Government wants you to switch from

Netflix to an online short course during coronavirus isolation

. Updated April 13, 2020. https://www.abc.net.au/news/2020-04-14/online-courses-to-keep-you-busy-during-coronavirus-isolation/12144718 Accessed April 29, 2020 .

29.

Greenstone

, Nigam

. Does social distancing matter? University of Chicago, Becker Friedman Institute for Economics Working Paper 2020-26. 2020.

30.

McCarthy

. Social distancing efforts have cemented into

U.S

. life. Updated April 13, 2020. https://news.gallup.com/poll/308252/social-distancing-efforts-cemented-life.aspx Accessed April 29, 2020 .

31.

Strub

. Will Instagram's New “Stay Home” sticker encourage social distancing?

Forbes

. March 21, 2020. https://www.forbes.com/sites/chrisstrub/2020/03/21/stayhome/#7d67ec1779e5 Accessed February 2, 2022 .

32.

Brown

. How

Snapchat

, Instagram and others are teaching kids

Gen Z about coronavirus

. USA

Today

. April 1, 2020. https://www.usatoday.com/story/tech/2020/04/01/coronavirus-snapchat-instagram-and-others-remind-teens-wash-hands/5101865002/ Accessed February 2, 2022 .

33.

Tait

. Pandemic shaming: is it helping us keep our distance? April 4, 2020. https://www.theguardian.com/science/2020/apr/04/pandemic-shaming-is-it-helping-us-keep-our-distance Accessed February 2, 2022 .

34.

Emond

, Maese

. COVID-19 strategies and policies of the World's Largest Companies. 2020. March 15, 2020. https://www.gallup.com/workplace/292334/covid-strategies-policies-world-largest-companies.aspx Accessed February 2, 2022 .

35.

Work-at-home after Covid-19—Our forecast. Global Workplace Analytics. https://globalworkplaceanalytics.com/work-at-home-after-covid-19-our-forecast Accessed April 29, 2020 .

36.

Docktherman

. The coronavirus is changing how we date. Experts think the shifts may be permanent. Time 2020. https://time.com/5819187/dating-coronavirus/ Accessed March 10, 2022 .

37.

Lee

. With COVID-19 Coronavirus, here are 15 ways to avoid shaking hands. Forbes. March 4, 2020. https://www.forbes.com/sites/brucelee/2020/03/04/with-covid-19-coronavirus-here-are-15-ways-to-avoid-shaking-hands/#635f5991227b Accessed February 2, 2022 .

38.

Dishman

. The delivery app landscape is changing and sustaining businesses during COVID-. 2020. March 30, 2020. https://www.uschamber.com/co/good-company/launch-pad/coronavirus-pandemic-food-delivery-businesses Accessed February 2, 2022 .

39.

Wiles

. Our #FlattenTheCurve graphic is now up on @Wikipedia with proper attribution & a CC-BY-SA licence Please share far & wide and translate it into any language you can! Details in the thread below #Covid_19 #COVID2019 #COVID19 #coronavirus Thanks to @XTOTL & @TheSpinoffTV. https://twitter.com/SiouxsieW/status/1237275231783284736?s=20 Accessed February 2, 2022 .

40.

Wilson

. More than half of Americans agree “Flattening the Curve” works. Civic Science. Updated March 23, 2020. https://civicscience.com/not-everyone-agrees-flattening-the-curve-actually-works/ Accessed April 29, 2020 .

41.

Cantu

. Texas city devises novel technique toward coronavirus prevention. Updated March 5, 2020. https://patch.com/texas/round-rock/texas-city-devises-novel-way-toward-coronavirus-prevention Accessed April 29, 2020 .

42.

McCarthy

. Three in four Americans worry about COVID-19 exposure. Gallup. Updated April 6, 2020. 2020. https://news.gallup.com/poll/307646/three-four-americans-worry-covid-exposure.aspx Accessed April 29, 2020 .

43.

Keeter

. People financially affected by COVID-19 outbreak are experiencing more psychological distress than others. 2020. March 30, 2020. https://www.pewresearch.org/fact-tank/2020/03/30/people-financially-affected-by-covid-19-outbreak-are-experiencing-more-psychological-distress-than-others/ Accessed February 2, 2022 .

44.

Operate your essential business. Updated April 28, 2020. https://sf.gov/operate-your-business-during-coronavirus-pandemic Accessed April 29, 2020 .

45.

Diamante

. Updated city of Austin order requires grocery stores to practice social distancing. Spectrum News. March 22, 2020. https://spectrumlocalnews.com/tx/austin/news/2020/03/23/updated-city-of-austin-order-requires-grocery-stores-to-practice-social-distancing Accessed February 2, 2022 .

46.

County of Los Angeles Department of Public Health. Safer at home order for control of COVID-19. 2020. https://covid19.lacounty.gov/wp-content/uploads/HOO_Safer-at-Home-Order-for-Control-of-COVID_04102020.pdf Accessed February 2, 2022 .

47.

OSHA. Guidance on preparing workplaces for COVID-19. 2020. https://www.osha.gov/Publications/OSHA3990.pdf Accessed February 2, 2022 .

48.

Steump

. Costco will not allow returns on high-demand items like toilet paper, water and more. Today. March 19, 2020. https://www.today.com/food/costco-not-allowing-returns-high-demand-items-toilet-paper-t176417 Accessed February 2, 2022 .

49.

McCarthy

. Americans feeling less connected as quarantine life wears on. 2020. April 17, 2020. https://news.gallup.com/poll/308882/americans-feeling-less-connected-quarantine-life-wears.aspx Accessed February 2, 2022 .

50.

Gale

Is “social distancing” the wrong term? Expert prefers “physical distancing,” and the WHO agrees. The Washington Post. March 26, 2020.

51.

Kumar

. Corona virus outbreak: keep physical distancing, not social distancing 2020. https://ssrn.com/abstract=3568435 or https://dx.doi.org/10.2139/ssrn.3568435 Accessed February 2, 2022 .

52.

Oeldorf-Hirsch

, McGloin

. Identifying the predictors of participation in Facebook Pictivism Campaigns. Soc Media Soc, 2017; 3:2056305117727637.

53.

Rall

. Facebook users can now add “Stay At

Home” frame to their profile photo

. Updated March 29, 2020. https://fox8.com/news/coronavirus/facebook-users-can-now-add-stay-at-home-frame-to-their-profile-photo/ Accessed April 13, 2020 .

54.

Stand against corona. https://standagainstcorona.org/ Accessed February 2, 2022 .

55.

Take the pledge: as a global citizen, I'm staying home! Global

Citizen.

https://www.globalcitizen.org/en/action/as-a-global-citizen-i-stay-at-home/ Accessed April 29, 2020 .

56.

Everett

JAC

, Colombatto

, Chituc

, Brady

, Crockett

. The effectiveness of moral messages on public health behavioral intentions during the COVID-19 pandemic. Preprint. 2020. DOI: 10.3123/4/osf.io/9yqs8.

57.

Jones

. Younger

Americans view coronavirus outbreak more as a major threat to finances than health

. 2020. April 7, 2020. https://www.pewresearch.org/fact-tank/2020/04/07/younger-americans-view-coronavirus-outbreak-more-as-a-major-threat-to-finances-than-health/ Accessed February 2, 2022 .

58.

Utych

, Fowler

. Age-based messaging strategies for communication about COVID-19. J Behav Public Admin, 2020; 3:1–14.

59.

Six Feet Saves. https://www.sixfeetsaves.org/ Accessed April 29, 2020 .

60.

“Six Feet

Saves” campaign spreads message on social distancing

. April 29, 2020. https://13wham.com/news/local/six-feet-saves-campaign-spreads-message-on-social-distancing Accessed February 2, 2022 .

61.

Constine

. Snapchat's

Zenly launches shelter-in-place leaderboard

. Tech

Crunch

. https://techcrunch.com/2020/03/24/zenly-stay-home/ Accessed March 10, 2022 .

62.

Cassino Dvid-19 may be kill. How men's misplaced sense of masculinity in the face of Covid-19 may be killing them. 2020. https://blogs.lse.ac.uk/usappblog/2020/04/09/how-mens-misplaced-sense-of-masculinity-in-the-face-of-covid-19-may-be-killing-them/ Accessed February 2, 2022 .

63.

Bish

, Michie

. Demographic and attitudinal determinants of protective behaviours during a pandemic: a review. Br J Health Psychol, 2010; 15:797–824.

64.

Braveman

, Kumanyika

, Fielding

, et al. Health disparities and health equity: the issue is justice. Am J Public Health, 2011; 101(S1):S149–S155.

65.

Oliver

TR.

The politics of public health policy. Annu Rev Public Health, 2006; 27:195–233.

66.

Murray

, Schaller

. Threat (s) and conformity deconstructed: perceived threat of infectious disease and its implications for conformist attitudes and behavior. Eur J Social Psychol, 2012; 42:180–188.

67.

Jurkowitz

, Mitchell

. Cable

and COVID-19: how

Americans perceive the outbreak and view media coverage differ by main news source

. 2020. April 1, 2020. journalism.org/2020/04/01/cable-tv-and-covid-19-how-americans-perceive-the-outbreak-and-view-media-coverage-differ-by-main-news-source/ Accessed February 2, 2022 .

68.

NPR/PBS NewsHour/Marist Poll Results: Coronavirus. Marist Poll. https://maristpoll.marist.edu/npr-pbs-newshour-marist-poll-results-coronavirus/#sthash.nBAgpZFo.dpbs Accessed April 29, 2020 .

69.

Barrios

, Hochberg

. Risk perception through the lens of politics in the time of the COVID-19 pandemic. 2020 Report Number: 0898-2937 National Bureau of Economic Research Working Paper Series: DOI: 10.3386/w27008.

70.

Adolph

, Amano

, Bang-Jensen

, Fullman

, Wilkerson

. Pandemic politics: timing state-level social distancing responses to COVID-19. medRxiv. 2020. DOI:10.1101/2020.03.30.20046326.

71.

Zhang

, Wang

, Zhu

, Wang

. Willingness to self-isolate when facing a pandemic risk: model, empirical test, and policy recommendations. Int J Environ Res Public Health, 2020; 17:197.

72.

Wise

, Zbozinek

, Michelini

, Hagan

. Changes in risk perception and protective behavior during the first week of the COVID-19 pandemic in the United States. R Soc Open Sci, 2020; 17:200742.

73.

Kuper-Smith

, Doppelhofer

, Oganian

, Rosenblau

, Korn

. Risk perception and optimism during the early stages of the COVID-19 pandemic. R Soc Open Sci, 2021; 8:210904.

74.

Oosterhoff

, Palmer

. Attitudes and psychological factors associated with news monitoring, social distancing, disinfecting, and hoarding behaviors among US adolescents during the coronavirus disease 2019 pandemic. JAMA Pediatr, 2020; 174:1184–1190.

75.

Strekalova

YA.

Health risk information engagement and amplification on social media: news about an emerging pandemic on Facebook. Health Educ Behav, 2017; 44:332–339.

76.

Kim

, Hwong

, Stafford

, et al. Social network targeting to maximise population behaviour change: a cluster randomised controlled trial. Lancet, 2015; 386:145–153.

77.

Siegrist

, Zingg

. The role of public trust during pandemics. Eur Psychol, 2014; 19. DOI: 10.1027/1016-9040/a000169.

78.

Guidry

JPD

, Jin

, Orr

, Messner

, Meganck

. Ebola on Instagram and Twitter: how health organizations address the health crisis in their social media engagement. Public Relat Rev, 2017; 43:477–486.

79.

Public holds broadly favorable views of many federal agencies, including CDC and HHS . April 2020. https://www.people-press.org/2020/04/09/public-holds-broadly-favorable-views-of-many-federal-agencies-including-cdc-and-hhs/ Accessed February 2, 2022 .

80.

Desaulniers

. How

Instagram influencers are trying to slow the spread of coronavirus

. 2020. Updated April 10, 2020. https://www.cnbc.com/2020/04/10/coronavirus-instagram-influencers-try-to-slow-covid-19-spread.html Accessed April 13, 2020 .

81.

Hutchinson

. Twitter reawakens profile verification to help identify authoritative voices on COVID-19 Outbreak. Social Media Today. Updated March 21, 2020. https://www.socialmediatoday.com/news/twitter-reawakens-profile-verification-to-help-identify-authoritative-voice/574629/ Accessed April 13, 2020 .

82.

Hou

, Lin

, Lu

, et al. Public exposure to live animals, behavioural change, and support in containment measures in response to COVID-19 outbreak: a population-based cross sectional survey in China. medRxiv 2020. DOI:10.1101/2020.02.21.20026146.

83.

Kwok

, Li

, Chan

, et al. Community responses during early phase of COVID-19 epidemic, Hong Kong. Emerg Infect Dis, 2020; 26:1575–1579. DOI: 10.3201/eid2607.200500.

84.

Cava

, Fay

, Beanlands

, McCay

, Wignall

. Risk perception and compliance with quarantine during the SARS outbreak. J Nurs Scholarsh, 2005; 37:343–347.

85.

Schurr

, Rodensky

, Erev

. The effect of unpleasant experiences on evaluation and behavior. J Econ Behav Organ, 2014; 106:1–9.

86.

Governor Abbott waives certain regulations to allow delivery of alcohol from restaurants and to support hospitality industry. 2020. March 18, 2020. https://gov.texas.gov/news/post/governor-abbott-waives-certain-regulations-to-allow-delivery-of-alcohol-from-restaurants-and-to-support-hospitality-industry Accessed February 2, 2022 .

87.

Davis

. States boost hospitality industry with booze delivery and takeout sales. US News. March 19, 2020. https://www.usnews.com/news/best-states/articles/2020-03-19/more-states-offer-alcohol-delivery-and-takeout-amid-coronavirus Accessed February 2, 2022 .

88.

Bodas

, Peleg

. Self-isolation compliance in the COVID-19 era influenced by compensation: findings from a recent survey In Israel. Health Aff (Millwood), 2020; 39:936–941.

89.

Leontsini

, Winch

. Increasing handwashing with soap: emotional drivers or social norms?. Lancet Global Health, 2014; 2:e118–e119.

90.

. How to use psychology to convince people to take social distancing seriously SLATE. https://slate.com/technology/2020/03/coronavirus-social-norms-psychology.html Accessed April 13, 2020 .

91.

What steps have states taken to address coronavirus?. National Governors Association. https://www.nga.org/coronavirus/#glance Accessed April 29, 2020 .

92.

Hussam

, Rabbani

, Reggiani

, Rigol

Habit formation and rational addiction: a field experiment in handwashing. Harvard Business School BGIE Unit Working Paper No. 18-030, 2017.

93.

Cure

, Van Enk

. Effect of hand sanitizer location on hand hygiene compliance. Am J Infect Control, 2015; 43:917–921.

94.

Cathey

. Fauci: ‘In a perfect world’ Americans would stop shaking hands. https://abcnews.go.com/Politics/fauci-perfect-world-americans-stop-shaking-hands/story?id=70062797 Accessed February 2, 2022 .

95.

Dalton

, Corbett

, Katelaris

. Pre-emptive low cost social distancing and enhanced hygiene implemented before local COVID-19 transmission could decrease the number and severity of cases. Med J Aust, 2020; 212:1.

96.

Guidry

, Jin

, Orr

, Messner

, Meganck

. Ebola on Instagram and Twitter: how health organizations address the health crisis in their social media engagement. Public Relat Rev, 2017; 43:477–486.

97.

Frellick

. Flattening the curve: viral graphic shows COVID-19 containment needs. Updated March 13, 2020. https://www.medscape.com/viewarticle/926806 Accessed April 13, 2020 .

98.

Dreibelbis

, Kroeger

, Hossain

, Venkatesh

, Ram

. Behavior change without behavior change communication: nudging handwashing among primary school students in Bangladesh. Int J Environ Res Public Health, 2016; 13:129.

99.

King

, Vlaev

, Everett-Thomas

, Fitzpatrick

, Darzi

, Birnbach

. “Priming” hand hygiene compliance in clinical environments. Health Psychol, 2016; 35:96.

100.

Coronavirus safety for essential businesses. https://sf.gov/coronavirus-safety-essential-businesses Accessed April 13, 2020 .

101.

Kite

, Foley

, Grunseit

, Freeman

. Please like me: Facebook and public health communication. PLoS One, 2016; 11:1–16.

102.

Pfattheicher

, Nockur

, Böhm

, Sassenrath

, Petersen

. The emotional path to action: empathy promotes physical distancing during the COVID-19 pandemic. Phychol Sci, 2020; 31:1363–1373.

103.

Lokhorst

, Werner

, Staats

, van Dijk

, Gale

. Commitment and behavior change: a meta-analysis and critical review of commitment-making strategies in environmental research. Environ Behav, 2013; 45:3–34.

104.

Rogers

, Milkman

, Volpp

. Commitment devices: using initiatives to change behavior. JAMA. 2014; 311:2065–2066. DOI: 10.1001/jama.2014.3485.

105.

Baum

, Jacobson

, Goold

. “Listen to the people”: public deliberation about social distancing measures in a pandemic. Am J Bioeth, 2009; 9:4–14.