COVID-19 Prevention via the Science of Habit Formation

Abstract

The coronavirus disease 2019 (COVID-19) continues to claim lives worldwide. We propose that the science of habit formation offers strategies to increase adherence to COVID-19 prevention behaviors and has the potential to be lifesaving, particularly for high-risk groups. Eight elements of habit formation are highlighted here: addressing incorrect beliefs, setting goals, devising an action plan, establishing contextual cues, adding reinforcement, engaging in repetition, aiming for automaticity, and recognizing that change is difficult. In addition, we offer a set of strategies for forming new habits and eliminating existing habits to contain the spread of COVID-19. These strategies are derived from habit-formation principles and behavior-change techniques and can inform future research on treatment development. With the COVID-19 pandemic still raging, there is currently an urgent need to jump-start the state of knowledge on habit-formation processes and interventions.

Keywords

habit formation habit elimination COVID-19

The coronavirus disease 2019 (COVID-19) continues to claim lives worldwide. Although recommendations to contain the spread of COVID-19 have been released by the World Health Organization, neither knowledge nor intention to follow such recommendations alone necessarily lead to action by the public (Webb & Sheeran, 2006). In addition, to enact COVID-19 prevention behaviors, we need to refashion core aspects of our lives. Although several of these behaviors may already be in our behavioral repertoires (e.g., handwashing), they may need to be altered to provide effective protection (e.g., handwashing should be more frequent and thorough). Other behaviors are likely to be entirely new (e.g., social distancing, wearing a face mask). Of concern, data from the H1N1 epidemic showed that the proportion of people who routinely engaged in preventive behaviors was low (Rubin et al., 2010). There is no reason to suspect better for COVID-19 prevention behaviors.

Our focus is on one powerful pathway to behavior change—habit formation. A habit is defined as a learned action that is performed with minimal cognitive effort (Lally & Gardner, 2013; Wood & Neal, 2007). We propose that the science of habit formation should be leveraged to ensure that behaviors that prevent the spread of COVID-19 become habitual and to ensure that behaviors that spread COVID-19 are eliminated from our behavioral repertoires. We have two goals in this article. First, we propose eight elements of habit formation that are highly relevant to COVID-19 prevention behaviors. As will become evident, the basis for the eight components is habit-formation theory (e.g., Gardner et al., 2014; Wood & Neal, 2007). In brief, habit formation occurs when a stable contextual cue comes to trigger an automatic impulse to engage in the habit via repetition. Repetition reinforces the behavior–context association. Goals and rewards or reinforcers motivate repetition. With ongoing repetition, the context becomes sufficient to activate the association. In other words, the context triggers the impulse to perform the behavior with minimal cognitive effort or intention. That is, the habit has become more automated and less reliant on one’s goals. Our second goal in this article is to offer strategies that might be considered for inclusion in a behavioral intervention to promote habit formation for COVID-19 prevention behaviors and to eliminate existing habits that may spread COVID-19. These strategies were derived by leveraging the science of habit formation and behavior-change theory.

Although we mostly focus on habit formation by individuals, we also highlight the need for population-level actions that support individual-level efforts to develop COVID-19 prevention habits and to eliminate habits that may spread COVID-19.

Elements of Habit Formation

Identify and address incorrect beliefs

There are many incorrect beliefs about COVID-19 prevention behavior (e.g., “If I wear a face mask, I will become ill or pass out”) as well as a distrust of experts. Given prior research showing that misinformation changes behavior via beliefs and intentions (Tan et al., 2015), incorrect beliefs are likely to constitute major barriers to engagement in COVID-19 prevention behaviors (Earnshaw & Katz, 2020). Hence, addressing incorrect beliefs is a necessary foundation for habit formation. Valid beliefs about the transmission and prevention of COVID-19, according to habit theory, will increase motivation and spur on goal setting (Lally & Gardner, 2013).

An important domain of research ahead is to document the range of incorrect beliefs held and devise strategies to correct them. Promisingly, researchers combining cognitive psychology, social psychology, and affective science have provided a window into population-level strategies for addressing incorrect beliefs, which include debunking misinformation using fact checking and corrections, nudges to encourage consideration of accuracy, and persuasion approaches such as emphasizing the benefits to the individual and of protecting others (Van Bavel et al., 2020). For widespread distribution, it is possible that these strategies could be embedded in social-media platforms (Pennycook et al., 2020).

Set goals

Public health experts specify the COVID-19 prevention behaviors that must be adopted. Of course, each individual must then make their own decisions and set their own goals for adherence to these recommendations. Goal setting is known to be most effective when goals are specific and sufficiently challenging (e.g., “I will eliminate touching my face while at work”), not vague or open-ended (e.g., “I will do my best to follow the recommendations”; Locke & Latham, 2002), and when they are set publicly and set by a group (e.g., families or members of a workplace could set COVID-19 prevention goals and post them on social media or the workplace website; Epton et al., 2017).

Unfortunately, goal pursuit is demanding of cognitive resources and thus can be derailed under taxing, high-stress-load conditions. Given the worry and anxiety associated with the pandemic, setting goals to promote adherence to COVID-19 prevention behaviors is an important first step, but achieving said goals will be easily perturbed. This underscores the critical importance of ensuring that COVID-19 prevention goals become habits.

Devise an action plan

Action planning facilitates individual-level behavior change across multiple domains of health and is defined as consciously devising a detailed plan as to how, when, and where goals will be enacted (Hagger & Luszczynska, 2014). Action planning is particularly important for the multistep habits necessary for COVID-19 prevention (e.g., getting tested, grocery shopping, preparing a socially distanced gathering). In the context of COVID-19, separate action plans should be developed for adopting COVID-19 prevention habits and for eliminating existing habits that spread COVID-19 (see Table 1).

Table 1.

Suggestions for Future Research on Treatment Development: Strategies to Promote Adherence to COVID-19 Prevention Behaviors and Associated Behavior-Change Techniques

Strategy	Behavior-change technique
Basic building blocks
Assess for and address incorrect beliefs.	Information about health consequences
Assess the patient’s current behavioral repertoire to identify COVID-19 prevention habits to be formed and existing habits to be eliminated.	Problem-solving or feedback on behavior
Acknowledge that change is difficult.	Information about antecedents
Review the pros and cons of change.	Pros and cons
Monitor progress.	Self-monitoring of behavior
Guide the process of developing new habits and eliminating unwanted habits.	(See sections below)
Forming new habits
Set goals for the habit to be formed (e.g., wear a face mask outside).	Goal setting (behavior)
Devise an action plan, including identifying behaviors that instigate or execute COVID-19 prevention behaviors.	Action planning
Establish contextual cues to engage in COVID-19 prevention behaviors (e.g., leaving the house could be a cue to putting on a face mask). Distinguish between cues that instigate the habit and cues that execute the habit.	Prompts or cues
Capitalize on established cue-response structures of existing habits to hasten learning new habits (e.g., always leave face mask near house keys).	Associative learning
Encourage repetition and emphasize that repetition in a consistent context leads to habit formation through associative learning (e.g., wear a mask every time you leave the house).	Instruction in how to perform a behavior or context-dependent repetition
Use implementation intentions.	Action planning
Devise reinforcers (e.g., discuss and help derive personalized benefits to wearing a face mask).	Imaginary reward, nonspecific incentive
Eliminating unwanted habits
Set goals for the habit to be eliminated (e.g., touching one’s face).	Goal setting (behavior)
Devise an action plan, including identifying behaviors that instigate or execute unwanted behaviors.	Action planning
Identify the contextual cue or cues (e.g., hair tickling skin). Distinguish between cues that instigate the habit and cues that execute the habit.	Problem-solving
Reduce exposure to the identified cues (e.g., tying hair back before going outside).	Avoidance or reduction of exposure to the cues for behavior
Uncover the reinforcers (e.g., relief from tickling sensation).	Problem-solving
Conceptualize substitution behaviors that achieve the reward (e.g., touching face with clean hands or an uncontaminated barrier).	Behavior substitution, habit reversal
Engage in the steps to form a new habit (previous section of this table) for the substitute.

Note: Behavior-change techniques are derived from Michie et al. (2013, 2014).

One type of detailed action planning is implementation intentions (Gollwitzer, 1999). Meta-analyses have documented moderate to large effects of implementation intentions for goal attainment (e.g., Toli et al., 2016). A COVID-19 example that incorporates the general format is, “When I have to leave home to pick up my medications from the pharmacy this afternoon, I intend to put on my mask, which I left near my keys and wallet.” The next step is to write down this commitment, visualize it as vividly as possible, and then repeat this process a few times. Counter-habitual implementation intentions also facilitate the elimination of unwanted habits via substitution (Adriaanse et al., 2011). The structure is, “If I see a close friend at a store whom I want to hug, then I will bow from a distance instead.” Again, this is written down and visualized.

In addition, it is helpful to distinguish between behaviors that involve habit instigation and habit execution (Gardner et al., 2016). Habit instigation refers to selecting and initiating behavior that automatically cues the COVID-19 prevention behavior unless sufficiently opposed, such as the process of finding one’s face mask before leaving the house. Habit execution refers to enacting the preparations or the habit itself, such as positioning one’s mask over one’s face before leaving the house. In a different context, Gardner et al. (2016) reported that measures of habit instigation are more predictive of enacting the desired habitual behavior, relative to measures of habit execution. There is a need to determine whether the importance of habit instigation replicates in the context of COVID-19 prevention behaviors because this knowledge could streamline the focus for habit formation.

A final issue relevant to action planning is that ongoing monitoring of progress toward goals is important because it highlights discrepancies between the current and desired use of the behaviors of interest (Harkin et al., 2016). Although self-monitoring should form the core of a provider-delivered intervention (see Table 1), use of self-monitoring by individual members of the public on their path to developing COVID-19 prevention habits is unlikely to be realistic for the majority given the motivation required.

Establish contextual cues

The power of cues was demonstrated in Pavlov’s classic experiments. In a similar way, habits are formed via the direct association between a cue and a response. We must select cues to desired new habits that are salient, accessible, and perceptible (Gardner & Lally, 2018). In regard to COVID-19 prevention behaviors, we should encourage people to establish cues. Reminders can serve an important role here. For example, a colorful note pasted on one’s office computer (for an office worker) or cash register (for a worker in a store) may form a salient and accessible reminder to notice the cues to touching one’s face throughout the day (e.g., a slight tingling, almost itchy feeling near one’s eyes). These cues then become the basis for habit-elimination strategies (see Table 1).

A key feature of a cue that successfully promotes habit formation is consistency. Pimm et al. (2016) reported that people who consistently exercised with the same people, in the same part of their routine, or in the same mood reported stronger physical activity habits. In addition, Judah et al. (2013) demonstrated that an established habit can serve as a cue to forming a new habit. For COVID-19, we can leverage current habits as cues to new habits. For example, if we usually take off our shoes as we arrive home, this could serve as a cue for heading straight to the sink to engage in thorough handwashing.

There is also evidence to suggest that people can capitalize on moments of change, such as a change of job or a house move (Verplanken & Wood, 2006). These are natural life events that involve less contact with powerful old cues for unwanted habits. Shelter-in-place orders are population-level major discontinuities that are likely to be highly advantageous for interrupting prior cue-habit associations at the individual level and for providing opportunities to build new associations.

According to the law of least effort, people can plan how to position cues to make it easy to engage in desired habits and hard to engage in unwanted habits. This can apply at both the individual and population levels. In other words, a strong focus on changing our environment is likely to be of prime importance. An example of a population-level cue is to provide hand sanitizer at the door of the supermarket. An example of an individual-level cue is to position our face mask near our house keys and wallet. Relatedly, Rothman et al. (2015) proposed introducing “behavioral friction” (p. 703) to existing contexts to make it harder for people to follow their unwanted habits (e.g., shops refusing to serve customers who do not wear a face mask).

Lastly, it may be possible to achieve habit formation involving multiple behaviors by devising a cue that triggers a tightly coupled bundle of desired behaviors that can be chunked together and activated as one unit (Spring et al., 2012). For example, on arriving home from school, a behavioral bundle for high schoolers might be to arrive at the front door (the cue) and then change their clothes, place them in the washing machine, and then wash their hands.

Add reinforcement

Thorndike’s law of effect states that if a behavior produces a reinforcing outcome, that behavior will strengthen. Thus, careful analysis and strategic use of reinforcers will facilitate habit formation. The positive natural consequence of COVID-19 prevention behaviors, such as not contracting the virus, is delayed. Thus, it is unlikely to constitute a reinforcer of behavior change (Hall & Fong, 2007). Hence, other types of reinforcers must be harnessed. For example, there is evidence that thinking about the impact of the behavior on other people motivates action (Rothman et al., 2015). Hence, emphasizing that adhering to COVID-19 prevention behaviors protects other people may serve as a reinforcer. There may be ways to increase positive associations with the actions we wish to build into habits. At the individual level, perhaps there are immediate advantages of wearing a face mask (e.g., keeping warm) that can be emphasized. At the population level, a national public office could issue text messages that ask “Have you used your mask today? REPLY with Yes or No.” If yes, a reinforcer is sent (“Great work! ”).

Engage in repetition

A next critical element is to repeat or practice the new behavior in the presence of the same contextual cues. With repetition, the habit starts to form, and one’s intentions and goals related to that behavior gradually become less influential. Naturalistic longitudinal studies have demonstrated that the amount of repetition needed to form a habit varies across behaviors and is surprisingly high, from 18 days to 36 weeks (Lally et al., 2010). Many of the COVID-19 prevention behaviors are performed multiple times daily (e.g., handwashing). This frequency provides daily opportunities for repetition, which bodes well for habit formation. Implementation intentions, described above, also promote repetition in the absence of natural opportunities.

Aim for automaticity

In most definitions of a habit, automaticity is a critical component. When a habit is performed with minimal cognitive effort, it has become automatic. Automaticity is particularly important for COVID-19 prevention behaviors because it ensures performance in the presence of other challenges that consume cognitive capacity, such as anxiety. However, it is unlikely that a cue will ever entirely automatically and mindlessly trigger engagement in a COVID-19 prevention behavior such that it is no longer under any volitional control (Maddux, 1997). More realistically, a cue may come to automatically trigger a decision-making process that, in turn, may result in engagement with the COVID-19 prevention behavior (Maddux, 1997). In other words, COVID-19 prevention habits might be mindful decisions that are automatically prompted by contextual cues and repetition.

Change is difficult

Habits tend to be relatively insensitive to change. Acknowledging that COVID-19 prevention behaviors go against our evolutionarily endowed preferences for seeing facial expressions and for standing closer to others than the currently required 6 ft may also be helpful (Sorokowska et al., 2017). In other words, people must adapt to a new awkwardness in person-to-person interactions, which will likely add to the difficulty developing COVID-19 prevention habits. Of note, when there are strong downsides to change, an effective standalone intervention is an honest review of the pros and cons of engaging in COVID-19 prevention behaviors (Collins et al., 2014).

Implications for Intervention

There is an urgent need for empirically grounded intervention-development research in this arena (Onken et al., 2014), particularly for people at high risk for catching COVID and those at high risk for spreading COVID-19. A behavioral intervention to promote habit formation for COVID-19 prevention behaviors—using the principles outlined here—is likely to mitigate harm. Drawing from the science reviewed as well as Gardner et al. (2020), we list a set of strategies in Table 1 that might be included in such an intervention. These strategies are offered as a stimulus for further development and empirical testing (Onken et al., 2014). Each principle of habit formation is linked to an evidence-based behavior-change technique included in the behavior-change taxonomy (Michie et al., 2013). This taxonomy is grounded in the behavior-change-wheel theoretical framework (Michie et al., 2014), which guides an understanding of a target behavior in its larger context to support designing interventions that will be most effective in promoting change. Table 1 is written for a situation in which a provider is delivering the habit-formation intervention to a client from a high-risk group. It could be adapted for groups, classes, and individual self-administration, although it is acknowledged that the latter requires a high level of motivation (Lally & Gardner, 2013).

Conclusion

We join other scholars in recognizing the great potential to harness the social and behavioral sciences at this critical juncture (Michie et al., 2020; Van Bavel et al., 2020). Our central question is how the science of habit formation can be leveraged to improve adherence to COVID-19 prevention behaviors. The eight elements of habit formation discussed are a first set of principles. However, an enormous amount has yet to be discovered about which of these are essential, and there is a tremendous opportunity to study the process of habit formation, particularly the interplay between mindful decision-making and true automaticity in habit formation (Maddux, 1997).

Finally, we must consider the many challenges that will be encountered by individuals and communities as they seek to develop COVID-19 prevention habits. For example,

Individuals living in overcrowded conditions may not be able to practice social distancing, those whose livelihoods depend on frequent and close interactions with others may not be able to afford it, and those without access to clean water and soap would not be able to wash their hands frequently. Other individuals may simply not be aware of the guidelines, may not understand the specific steps to follow, or . . . may not be convinced of the need to practice these behaviors. (Doyle et al., 2020, para. 2)

A set of strategies to promote habit formation for COVID-19 prevention behaviors is proposed to increase safety for the many people who are experiencing these challenges. A self-administered version could be disseminated to the general public. Fortunately, there may be positive ripple effects from spreading this knowledge because habits developed by one person in a social network tend to be adopted by others (Bond et al., 2012). In sum, with the COVID-19 pandemic still raging, there is currently an urgent need to jump-start the state of knowledge on habit-formation processes to flatten the curve and save lives.

Footnotes

Acknowledgements

A. G. Harvey has received book royalties from the American Psychological Association, Guilford Press, and Oxford University Press.

Transparency

Action Editor: Robert L. Goldstone

Editor: Robert L. Goldstone

ORCID iDs

Allison G. Harvey

Catherine A. Callaway

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COVID-19 Prevention via the Science of Habit Formation

Abstract

Keywords

Elements of Habit Formation

Identify and address incorrect beliefs

Set goals

Devise an action plan

Establish contextual cues

Add reinforcement

Engage in repetition

Aim for automaticity

Change is difficult

Implications for Intervention

Conclusion

Recommended Reading

Footnotes

Acknowledgements

Transparency

ORCID iDs

References