What Face Masks Teach Us About Behaviour Change

Ultimately the innovation and change process begins and ends with one basic premise – listen first

How do new ideas and practices take hold? And why do some practices that require behaviour change get adopted more quickly than others?

COVID-19 has meant we have all had to embark on some very significant changes to our lives:

  • Queuing to get into supermarkets.
  • More regular handwashing.
  • Not hugging or shaking hands with people we know or love.
  • Wearing masks in public.

Some of these have been adopted easily whilst others are more problematic and have faced resistance. Understanding how and why some get adopted without question and others don’t is crucial if you’re involved in innovation or change management.

Many of the very best innovations in history took a long time to catch on. The train, the personal computer, the mobile phone – things that have truly changed the world but were not accepted immediately, and faced huge resistance from doubters.

Some of the behaviour change required by COVID-19 has been adopted more easily than others because they build upon clear pre-existing norms.

Queuing to get into a supermarket was easily adopted in the UK – because the British are particularly good at queuing. Even to the extent of being obsessive about other countries not being good at it. Queuing seems to have become an established social norm in the early 19th Century, a product of more urbanised, industrial societies which brought masses of people together. But it wasn’t until World War II and rationing that Britain’s reputation as civilised queuers was established.

Handwashing as you enter a shop or bar builds upon an established norm common in medical environments.

Like most norms though – handwashing in hospitals wasn’t adopted quickly. Although washing with soap and water has been considered a measure of personal hygiene for centuries the link between handwashing and the spread of disease was established only a couple of hundred years ago. The physician Ignaz Semmelweis advanced the idea of “hand hygiene” in medical settings by observing that when students and doctors washed their hands with an antiseptic solution before examining women during childbirth, infection and maternal death fell by 90%.

A discovery like that would spread like wildfire surely?

Not so – Semmelweis attempted to spread these hand hygiene practices, even confirming his findings in a different hospital. But he was largely ignored, even derided, and died at the age of 47 in an asylum.

Whatever your transformation roadmap says some of the best and most sustainable change takes decades, not months, to achieve.

Some health workers have struggled to adopt consistent approaches to hand washing even up to the last few years. One of the most effective ways adoption was boosted was simply by making hand dispensers much more prevalent and available. People will change their behaviour if the effort involved is minimal. Taking this from medical settings and applying it in pubs and restaurants is a significant leap forward but one that is understandable to the public at large.

As Chris Bolton has written, COVID-19 will have all sorts of long term effects on behaviour change, and some unintended consequences. Will ritualistic hand washing as we enter shops and other establishments continue long after the virus has gone? We won’t know for a long time.

With any change our resistance is usually not overt, just passive. With passive innovation resistance we don’t resist a product but rather the change that the innovation requires us to make. By making the right thing to do much easier we can boost adoption and spread the change.

Which brings us to face masking.

Why is facemasking so controversial that people will organise rallies against wearing them or feel so passionately about them that they will change their Twitter profile picture to include one? One of the reasons masking is divisive is that it doesn’t build on any established norm. In the West at least, it flies in the face of them.

Masked up in Phnom Penh 2015

Back in 2015 I was travelling in a Tuk Tuk across a traffic clogged city in Cambodia. The driver pulled over , ran into a roadside shop and promptly presented us with two masks, saying we’d have a better journey wearing one. It was a simple act of kindness, of great customer service , rather than an enforced change. Little did we know that five years later we’d be wearing them in Sainsbury’s.

In parts of the East, face masking builds upon a long standing tradition. For instance, in Japan the custom of facemask-wearing began in the early 20th century, during the Spanish Flu epidemic. A few years later, the Great Kanto Earthquake of 1923, triggered an inferno that filled the air with smoke and ash for weeks, and air quality suffered for months afterward. A second global flu epidemic in 1934 cemented Japan’s love affair with the facemask, which then began to be worn with regularity during the winter months to prevent coughs and colds. Today masks are even worn by some young people as a fashion statement.

However as Jeff Yang writes, the predilection for face masks in public in Asia builds upon a tradition that goes much further back in time, into Taoism and the health precepts of Traditional Chinese Medicine, in which breath and breathing are seen as a central element in good health. The 2002 SARS outbreak and the 2006 bird flu panic, have seen face masking increase exponentially and without controversy, because it builds upon deep cultural beliefs.

In the West, no such cultural beliefs exist. Covering parts of your face is viewed as a suspicious act and has links with anti social behaviour and criminality. Additionally the adoption of face masking has been further complicated by the lack of something all change needs to succeed: a good story behind it.

The story of masking is inconsistent: first we were told they were of no use, then we were told they were good. The application of the story is also confusing: in England they are mandatory in shops, but at the weekend I popped over the border into Wales where they are not and people are free to do as they wish.

Queuing to get into shops is a simple leap for us to make.

You can argue about actual evidence all day long but inconsistent application and poor storytelling are hugely damaging to the adoption of new practice.

Washing hands as you enter a building is asking a bit more from us – but we kind of get it.

Wearing masks is a completely alien concept and therefore resistance is guaranteed.

And that’s the lesson to take back into our organisations and communities when we want to make change:

  • Try to build on existing cultural norms where possible.
  • Make it something that the community can adapt to without much effort.
  • Be consistent with your story telling about why change is needed in the first place.

Change only sticks when we understand the modern information ecosystem and have trusted communications with colleagues and communities.

Ultimately the innovation and change process begins and ends with one basic premise – listen first.


Image by Uki Eiri from Pixabay

How Can We Move From Demand Led Service In The ‘New Normal’?

In the early hours of Good Friday I found myself undergoing emergency surgery after a complication during an earlier test. Even in the midst of some pretty intense pain I was unwilling to go to hospital – a mixture of fear of contracting a certain virus and some overly optimistic thinking about my super human ability to recover without any professional intervention. It was probably Karen wilfully ignoring my instructions not to call an ambulance that saved my life.

Eleven days later I was discharged from hospital after major surgery and two COVID-19 tests. Family and friends were unable to visit so I had a lot of time for self reflection, and to observe from the inside how systems operate during periods of genuine crisis.

The term crisis is overused.  Every day the news is filled with stories about war, terrorism, crime, pollution, inequality, and oppression. There’s a health crisis, a housing crisis, a climate crisis , and a social care crisis. So many “crises” they have to jockey for position in order of seriousness.

What the COVID-19 crisis has done very effectively is to say “hold my beer” to the others – becoming the defining crisis of the moment.

One of the most interesting things about my experience of hospital was the apparent disconnect between the media reporting of what was happening on many wards, and my own actual experience.

Family expressed concern for the health workers without PPE at the same time as staff told me there wasn’t a problem. People told me the system was in meltdown when my observation was of staff continually adapting to new working practices based upon the evidence and experience of the previous day.  Even if the system was in ‘crisis’, at a local ward level people were pulling together and solving problems in new ways. Freed of some of the usual ‘rules’ people were succeeding despite the system rather than because of it.

The NHS is brilliant at coping with an emergency , both at scale and at the individual human level. I simply couldn’t fault my experience, from the operation to the recovery to the after care. The people ARE heroes. It’s not the time to pick fault with the system , but where it often falls down is in some of the basics. These are often things that are less urgent to professionals , but more important to us as citizens , such as communication and keeping us informed of progress.

This is not limited to the NHS , far from it. It’s a symptom of systems that are designed to be reactive rather than pre-emptive. They tend to be designed from a ‘service’ point of view – managing demand – rather than through person centred design, the principles of which are the opposite of service led design.

During my stay, staff noted how demand had dropped. People simply weren’t coming to Accident and Emergency anymore. The country had either stopped having heart attacks and strokes or were delaying reporting them.  This drop in demand isn’t limited to the NHS. Other social providers are seeing similar trends. The phenomenon has also occurred across the US and in parts of Asia.

So why has the system been able to manage demand, something that’s been a problem for decades, in just a matter of weeks?

Obviously , fear is playing a part. In a lockdown scenario people’s priorities have a major shift. Things that would once be major causes of anxiety get reordered in the face of a common enemy.

That said , there is something to learn from how the latent and underused power of community has been leveraged to protect our most precious resources.

People have begun supporting and caring for one another to an unprecedented extent, with community led groups popping up to address immediate needs in ways our organisations simply can’t. It is neighbours that have shown themselves to be the most useful support network in a physically distanced world.

YouGov have reported that only 9% of Britons want to return to life as normal after the end of the lockdown. 40% of people say they feel a stronger sense of community since the virus shut down normal life, while 39% said they had been more in touch with friends and family.

What this seems to indicate is that far from communities resenting a shift away from a passive provider-consumer relationship – they actually desire it. They want a greater say, they want more power to influence local decisions.

There’s a danger here of being overly optimistic as Simon Parker has warned. “Simply willing a better world is not enough. You have to dive into the complexity, dance with the system in its full, messy intractability”.

System change never comes easy. It means thinking beyond individual sectors and requires the whole system to work together, through health, housing, employment and social care. There’s opportunity here if we are brave enough. 

That said , a lesson so far from COVID-19 is that the best currency for change is local. People are discovering their neighbours for the first time, spending less time travelling to soulless business parks , and spending time and money where they live.

Powerful forces will resist any attempt to make this a new normal. It’s not how capitalism works.

However my recent experience has led me to believe that the organisations that emerge stronger from this crisis will be ones who have abandoned doing things to people, and moved to seeing themselves as equal partners with communities.

That requires making a move from telling to listening.

A move from obsessively managing demand to leveraging the skills in the community.

A move from filling the gaps with more services to closing the gaps through social connections.


 

 

Image by Queven from Pixabay 

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