Underlying Principles of a Covid-19 Behavioral Vaccine for a Sustainable Cultural Change

"[C]ohesive and coordinated policymaking action for delivering environmental events that favor adherence to protective behaviors at a large scale is key to reducing the length and severity of future outbreaks."

In the wake of the suffering COVID-19 has caused around the world, one might expect that sharing a common risk of infection and death would lead most citizens to adhere to experts' recommendations about behaviours that serve as an "immunisation" against contracting and spreading the virus. However, individuals' habits and choices are shaped by a wide range of conflicting environmental events. This paper aims at informing interventions to limit the spread of the contagion and prepare against any future outbreaks by developing a behavioural framework to interpret and prescribe both the individual and large-scale uptake of non-pharmaceutical measures.

First, the paper analyses barriers and facilitators to adherence to protective behaviours, offering the following definitions:

• Antecedents: cues to the type of consequence that will follow a response in each circumstance.
• Consequences: environmental events that affect behavioural classes, increasing or decreasing the probability of future occurrences.
• Contingency: the functional relationship between a behavioural class, antecedents, and consequences.

The first step in designing an intervention is to identify target behaviours. Knowing that a behaviour is affected by its relationship with antecedents and consequences, the second step is to describe the interactions between antecedent, behaviour, and consequences. The environment where behaviour takes place is a context containing antecedents that signal that the emission of a certain behavioural class may be followed by a set of consequences. Results can be achieved by adopting routines and practices that have been scientifically linked to reduce morbidity and mortality, thus functioning as a behavioural vaccine. In order to implement behavioural vaccines at the population level, stakeholders must first know and understand the variables and principles influencing individual engagement in protective measures.

Next, the paper describes the components of behavioural contingency (antecedent-behaviour-consequence) and ways to take them into consideration when developing a behavioural vaccine. It looks at topography (e.g., keeping at least 2 metres distance between one another), temporality (e.g., managing time to avoid crowds), frequency (e.g., in the case of handwashing), and effort (e.g., price of hygiene products). Some interventions to increase compliance with physical distancing include changing the salience of an antecedent by placing reminders at grocery stores or in other public spaces. Other interventions include the transfer of function with messages referring to physical distancing as a sign of respect and caring for others. The salience of antecedent stimuli can be increased through messages conveyed by news channels, international and governmental calls for action, public campaigns, and so on. For example, effective communication can improve face mask wearing by describing and showing models of how doing so may be a sign of respect for the community. Thus, these and other favoured environmental events may signal that protective behaviours are likely to be followed by social approval (consequence). That is to say, in such communications, it is necessary that the antecedents are salient and linked to the consequences of behaviour.

The effects of consequences on a behaviour depend on several factors, such as whether an individual's behaviour produces positive and delayed consequences or avoids aversive and immediate consequences. The paper explores the effects of competing consequences, aversive versus reinforcing consequences, and the paradox of immediate versus delayed consequences. For example, proximal physical contact produces immediate social reinforcers; however, it also produces delayed aversive consequences (getting infected). Previous studies have shown that delayed consequences have a reduced value. Impulsive choices intend a preference for the option that grants access to immediate reinforcers of lower magnitude (physical contact) and delayed aversive consequences (sickness), over the option that grants access to immediate aversive consequences (physical distance) and delayed reinforcers of greater magnitude (good health). Praise and approval for engaging in target behaviours provide immediate consequences that can show positive effects.

With a view to understanding the contingencies that may hinder behavioural change and the persistence of dysfunctional patterns at the individual level, the paper introduces an adapted version of the PIC/NIC Analysis. The initials of its acronym refer to potential functions, temporality, and probability of environmental consequences over analysed behaviors. PIC refers to positive, immediate, and certain events, whereas NIC refers to negative, immediate, and certain. The method allows one to systematically analyse the often concurrently antecedent and consequences of behaviour from the perspective of the performer. It can help understand the obstacles to behavioural change by rating consequences along 3 axes: (i) positive (P) or negative (N); (ii) immediate (I) or delayed (D); and (iii) certain (C) or uncertain (U). The paper replaces the positive and negative classification of consequences with reinforcing (R) and punitive (P) outcomes. Regarding antecedent events, the paper systematises their relational features according to their function on favouring behaviours' occurrence: (i) salient (S) or faded (F); and (ii) discriminative (D) or neutral (N). In addition, contextual events with the capacity of altering the reinforcing value of consequences are listed as motivating operations (MOs), which are contextual events that significantly alter the effects of consequences on behaviour (value-altering effect) and the evocative functions of antecedents (behaviour-altering effect). The paper puts forward an example of a functional analysis of physical distancing, which can be extended to other protective behaviours (e.g., hand washing, face mask wearing, isolation, and quarantine). It offers a PIC/NIC analysis for explaining some of the consequences of physical distancing that are not only contingent (PIC, NIC), but also uncertain to a lesser degree (PIU).

The paper then analyses how organised efforts across sectors of a society may be arranged, allowing for the implementation of a behavioural vaccine. Contagion control is described as the cumulative effect of large-scale adherence to protective behaviours. Cultural practices are shared behavioral patterns that, when accumulated, can positively and negatively influence the outcomes of a social issue, such as the rate of a virus spread. In the context of the COVID-19 pandemic, they can be measured as rates of engagement with protective behaviours advised by health authorities, whereas their cumulative effect is measured as infection and death rates, as well as social and economic indicators. Macrocontingency is an approach used to address the cumulative effect generated by several individual behaviours, which in sum can have a social impact (see Figure 2 in the paper). The conditional relation between coordinated efforts of individuals (or organisations) towards an aggregate product and a cultural consequence is termed a metacontingency. The recurrence of a network of contingencies is dependent on cultural consequences. Government, science, media, schools, services, and non-governmental organisations (NGOs) are possible agents in a coordinated response towards fostering change in behavioural patterns at the population level.

The paper guides the reader through elements and actions translated into general steps in which agents or agencies could engage to favour a rapid and successful implementation of cross-sector action to contain the spread of the virus. Key steps include:

1. Define a common behavioural goal.
2. Identify essential actions towards target behaviour.
3. Map essential roles and identify promising agents
4. Connect and coordinate actions.
5. Highlight outcomes from coordination.

Special attention is given to strengthening the coordination between agents, which is key to providing a cohesive environment that can design and sustain novel cultural practices. As noted here, in addition to the need for different sectors of society to act in a coordinated fashion, implementing a behavioural vaccine should be timely and consider the outbreak status in each region. Furthermore, "any intervention proposition must involve ethical respect for the community's practices....It is of the utmost importance that a functional analysis and the following behavioral interventions are transparent and follow agreed-upon guidelines. They should be in the interests of the public, community, and laws and follow scientifically proven measures."

In conclusion, this paper has highlighted the potential of developing a behavioural vaccine and outlined practical steps for applying it to promote sustainable cultural change that may protect against health, social, and economic losses in future outbreaks.