Behaviour change approaches to addressing mask use, physical distancing and handwashing

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The tables below identify several ‘risky’ or sub-optimal behaviours related to mask use, handwashing and physical distancing that could lead to increased transmission of infectious diseases, such as COVID-19. They describe the factors that may influence these behaviours, potential ways of addressing these behaviours and additional resources. It is important that we do not blame populations if they are adopting these ‘risky’ behaviours. Rather it is important to take time to listen to their concerns and understand what is driving their behaviour. It is also important that this is not used in place of learning from communities on an ongoing basis throughout outbreaks. All ideas from these tables should be adopted in discussion with community members and adapted to the local context. You may need to also adapt the activities to cover different settings – for example, the approaches used at a household level may need to be different to approaches in public settings (e.g. markets or transport hubs) or institutions (e.g. health centres, schools workplaces). If you need further advice on any of these topics, please go to the Global WASH Cluster website or use the other technical resources on the Hygiene Hub.

See the following tables below for summaries for 1) Mask Use 2) Handwashing and 3) Physical Distancing. Note that whilst the tables below were produced with COVID-19 in mind, principles and activities can be applied to other infectious diseases with the same preventive behaviours.

1) Mask Use

Risky behaviour: Incorrect wearing of masks

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Knowledge Comfort Norms Social support	Images showing how to wear/not wear a mask Staff in key areas (e.g. entrances to buildings) supporting people to use masks correctly Promoting masks that are comfortable, adjustable and desirable Conveying information about how incorrect mask use can still cause transmission.	WHO Infographic on do’s and don’ts of fabric mask use WHO infographic on do’s and don’ts of medical mask use Hygiene Hub resource on the evidence on masks. Video explaining why it is important to cover your nose with a mask as well as your mouth Tips for making masks more comfortable

Risky behaviour: Reusing or sharing masks

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Mask access Convenience Knowledge Soap and water access Waste disposal Disgust	Make sure everyone has access to at least 3 fabric masks as this will allow masks to be washed after each use. Provide people extra laundry detergent and potentially a clothes line to help with air drying. Avoid the use of medical masks except for people with COVID-19 symptoms, their careers and clinically vulnerable individuals. Supply enough medical masks to these individuals for them to replace masks at least once a day, train people how to use them and provide safe disposal mechanisms. Link mask cleaning to other familiar behaviours, such as cleaning underwear. Heighten disgust around masks that are not cleaned regularly by showing people that they become dirty quickly.	CDC advice on mask cleaning WHO mask FAQs, including advice on mask cleaning

Risky behaviour: Not wearing masks

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Mask access Regulation Affiliation Norms Social support Culture and fashion	Make sure everyone has access to at least 3 fabric masks as this will allow masks to be washed after each use. Provide clear guidance about when masks must be worn and have community members or staff to remind people to use them in these locations. Complement this with clear visual reminders. Remind people that they need to wear masks to protect others and position mask use as something that shows you care. Use norm based messaging to convey that others in the community believe mask wearing is the right thing to do. Make masks culturally appealing and fashionable.	Hygiene Hub resource on using behaviour change principles to promote mask use. CDC guidance on mask use WHO guidance on mask use. Videos explaining and visualising how masks preventing transmission (Example 1, Example 2) Case study of intervention to increase mask usage in Bangladesh

2) Handwashing

Risky behaviour: Hands are washed with water only

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Access to soap Handwashing facilities Belief that water is sufficient to clean hands	Provide people with more soap Provide people with products that are specifically for hand washing (e.g. liquid handwashing soap or sanitizer) Make sure that soap is always present at the handwashing facility – e.g. by creating a soap dispenser, soap dish or attaching it with a rope. Help people to realise that soap is the key ingredient to leaving hands truly clean. Example activities to do this might include glow germs or other low-cost versions of this (Example 1 - glitter hands, Example 2 - pepper surface, Example 3 - bacteria on bread).	Hygiene Hub resources on promoting handwashing when soap is scarce Wash’Em webinar including ideas for keeping soap at the handwashing facility and showing the power of soap.

Risky behaviour: Hands are not washed at critical times

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Access to handwashing facilities with soap and water Access to sanitiser Physical environment Knowledge	Make people aware of additional times for handwashing. Create new handwashing facilities in the places where people need to wash their hands. Adjust the physical environment to encourage handwashing. This could include adding nudges to cue handwashing.	Hygiene Hub guidance on handwashing times Global Handwashing partnership poster on COVID-19 handwashing occasions. IDS Handwashing Compendium Compendium of Hygiene Promotion in Emergencies Handwashing facility design in public places from WaterAid WINS and Hygiene Hub resource on using nudges to promote handwashing

Risky behaviour: Hands are not washed thoroughly

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Knowledge Convenience Water availability	Show why handwashing should be done for at least 20 seconds (Example 1 - UV experiment) Build handwashing facilities as this will help minimise water use and make handwashing easier. Increase disgust around unwashed hands.	Hygiene Hub resource on promoting handwashing in water scarce settings. IDS Handwashing Compendium Compendium of Hygiene Promotion in Emergencies Handwashing facility design in public places from WaterAid

3) Physical Distancing

Risky behaviour: Attending social gatherings

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Norms Culture/religion Physical environment Regulation Knowledge	Identify cultural or religious occasions when people normally come together and develop alternative plans with the community. Promote alternative ways for people to stay connected. Work with religious, cultural and community leaders to identify acceptable ways of maintaining physical distancing. Adjust or change physical spaces where people often gather to enable physical distancing. Use norms based messaging to show that people think physical distancing is the right thing to do. Explain why physical distancing is necessary in ways that are easy to understand (Example 1, Example 2, Example 3)	Hygiene Hub resource on physical distancing.

Risky behaviour: Being in close proximity to others in common gathering places

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Physical environment Norms Convenience Knowledge	Change the physical environment by using nudges such as markers on the ground or spacing seats. Limit the number of people allowed into a space at any one time. Adjust operational hours at health centres, distribution points and markets to enable fewer people to congregate. Encourage people to prioritise essential travel (e.g. do shopping once a week rather than daily). Provide context adapted ways of explaining how to maintain distance (Example 1 - WHO infographics , Example 2 - what 1-2 metres looks like).	Hygiene Hub resource on physical distancing. Hygiene Hub resource on doing hygiene kit distributions safely. Hygiene Hub resource on programme responses in camps and camp-like settings. Hygiene Hub resource on responses in camps and camp-like settings.

Risky behaviour: Physical greetings (handshakes, hugs, kisses)

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Norms Culture/religion Social support	Promote acceptable and fun alternatives to greetings Remind people that this is a short term measure the enable togetherness in the long term (e.g. this video from Nepal).	Alternative greetings cartoon from the WHO

Risky behaviour: Not isolating when experiencing symptoms.

Factors that may influence the behaviour	Examples of activities to address the behaviour	Resources
Fear Convenience Physical environment Social support Income and other personal responsibilities	Recognise and celebrate people who do the right thing. Provide people who are isolating with a care pack. Find ways to enable isolating individuals to remain connected with others. Set up local support systems to enable communities to deliver food and medicine to those who are isolating. Provide mental health support.	Resources for setting up community support groups to aid people who are isolating. Considerations for home based and community based care. Hygiene Hub resource on programme responses in camps and camp-like settings.

Editor's note

Written by: Global WASH Cluster
Reviewed by: Hygiene Hub
Version date: November 2022