The Complexity of Behavior Change Within the Context of the Coronavirus

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COVID 19 Closure

by Jeff Driskell, PhD, LICSW

     The unexpected and spontaneous arrival of the coronavirus crisis has had a dramatic impact on the health and well-being of individuals, families, and communities. Social workers are in a unique position to support those in crisis, as we are educated and trained to engage in brief interventions that foster health and wellness. Focusing on health and wellness is not new to the field of social work. The Centers for Disease Control and Prevention has established a set of guidelines that are deemed effective in preventing the acquisition and/or transmission of the COVID-19 virus.

    Among these guidelines is the practice of maintaining and keeping physical distance from others. This behavioral practice is known as physical distancing (aka social distancing). Maintaining physical distance sounds simple enough. Right? Well, quite the contrary.

    As we know with other health behaviors such as smoking and substance use, changing our behaviors and adopting healthier ones can be difficult. As an attempt to modify people’s behavior, local, state, and federal governments have implemented restrictions that support physical distancing. Some of these strategies include restricting dining establishments to take-out only, the closure of all non-essential businesses (such as barber shops and malls), encouraging avoidance of large gatherings, and the moving of schools and universities to an online virtual platform.

    The strategies put in place by local, state, and federal governments have been adopted by many individuals. Unfortunately, there are a number of people who are struggling to adhere to physical distancing protocol. Daily, the media share stories of physical distancing disobedience—for example, stories of college students celebrating spring break on the beaches of Florida, as well as images of adolescents playing basketball, which is a close contact sport.

    So why do some people adhere to and adopt the physical distancing protocol while others do not? You would assume that people would want to avoid contracting and/or spreading this potentially lethal virus. For years, the social sciences have been researching and studying factors that influence health behavior and behavior change. As a result, the social sciences have generated a wealth of knowledge that helps us to better understand individual health behavior and behavior change.

    Social workers and social work students specifically are no strangers to the concept of behavior change, as they are exposed to theories and models in their education and training. However, often lacking is the public health interdisciplinary perspective on behavior change.

    Public health professionals have been examining behavior in the context of prevention for several decades. As a result, we now have, more than ever, a better understanding of factors that influence health behavior and behavior change. Knowledge of these factors has led to the development and evolution of public health theories and models that help explain and predict why people change their behavior and why others do not.

    I will introduce three theories and models that relate to the coronavirus and physical distancing. They are the health belief model, theory of reasoned action, and social cognitive theory.  

Theories and Models

    Health Belief Model (HBM). The HBM is one of the most widely used models in helping to understand and predict behavior change. It has been used in a variety of health prevention programming, including HIV/AIDS prevention, seatbelt campaigns, and mammogram screening campaigns. The model focuses on understanding a person’s beliefs and attitudes (cognition) as they relate to the adoption of a health behavior.

    The specific constructs of the HBM include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy.

    Perceived susceptibility and severity together have been labeled as perceived threat. So how do these constructs relate to the coronavirus? Perceived susceptibility is linked to one’s belief around the chances of contracting the virus. Perceived severity is based on one’s belief of how serious the virus is along with the potential consequences of contracting it. Perceived benefits focuses on how one interprets the pros of adopting the new physical distancing behavior. Perceived barriers looks at the cons or the negative aspects of adopting the practice of physical distancing, which also includes the evaluation of both psychological and emotional costs. Self-efficacy addresses a person’s level of self-confidence in adopting and successfully implementing physical distancing.

    In a nutshell, for behavior change to occur and to be successful, people must see the coronavirus as a threat to their health, understand that adopting the new behavior (physical distancing) will result in positive outcomes/benefits, and feel confident in their ability to overcome any perceived barriers that may get in their way of taking action.

    Theory of Reasoned Action (TRA). As with the HBM, TRA has been used to explain and predict a variety of health-related behaviors, including the use of contraceptives, smoking/tobacco use, and substance use. This theory suggests that the biggest predictor of behavior change is the concept of intentions. Intention implies one’s readiness to engage in a specific health-related behavior.

    The theoretical concepts of TRA that feed and nourish intention include one’s attitude and subjective norms. A person’s attitude is based on the evaluation, both positive and negative, of the particular behavior in question. In relation to the coronavirus, a person may ask, “How important is it for me to practice physical distancing?” OR “Do I think physical distancing will really make a difference in keeping me safe from the virus?” Thus, if a person strongly believes that positive outcomes outweigh the negative, then they are more likely to have a positive attitude toward physical distancing.

    Subjective norms are linked to one’s peer/social network in terms of approving or disapproving of performing a specific behavior. For example, an individual’s level of motivation to practice physical distancing may be a result of whether it is valued or not by a peer/social group. If one’s peer/social group has a strongly held belief that practicing physical distancing is important to preserve one’s health from the coronavirus, it is more likely an individual will be motivated to adopt that behavior.

    Social media have been playing a role in trying to get those who are not practicing physical distancing to stay home. For example, many people are changing their Facebook profile pictures with a frame that reads “#StayHome.” This is an example of a subjective norm being promoted by one’s peer/social network, which in turn can have an impact on one’s intentions.

    In summary, for a person to adopt the practice of physical distancing, that person must have strong intentions to do so. The ingredients that strengthen these intentions are a person’s attitude toward the new behavior and the influence of subjective norms.

    Social Cognitive Theory (SCT). Elements of SCT are reflective of social work’s emphasis on the ecological perspective. Social cognitive theory proposes that behavior change is influenced by the reciprocal interaction between a person, the person’s environment, and their behavior. This theory contains approximately nine concepts. For the purposes of this article, I will highlight the three most relevant concepts, which will add to our understanding of behavior change. Please note that self-efficacy is a key concept of SCT, but it was addressed above under HBM. The concepts include observational learning, outcome expectancies, and emotional coping.

    Whether a person adopts a protective health behavior (e.g., physical distancing) is often influenced by observing others (observational learning) within a person’s peer/social network. For example, if a person continues to witness social media posts of their peer group practicing physical distancing by using alternative ways of socializing (e.g., use of Zoom for virtual game night or happy hour) and doing so with some success, they are more likely to adopt the new behavior.

    The concept of outcome expectancies assesses the worth and possible consequences of adopting a new health behavior. For example, media have highlighted that some who are not practicing physical distancing have expressed fears of becoming depressed or too isolated. In weighing the possible benefits and consequences of adopting physical distancing, some feel the emotional toll is too much of a burden, and as a result, the new behavior is not adopted.

    This leads to the final concept, which is emotional coping. If and when a person adopts physical distancing, does that person have the capacity and skills necessary for coping with the potential emotional impact? If a person lacks the ability to cope with the negative emotional state associated with physical distancing, they may reverse the practice and begin to disobey such practices, thus putting themselves and others at potential risk of acquiring and/or transmitting the virus.

Conclusion

    The COVID-19 crisis and its resulting implications have underscored the importance of understanding behavior and behavior change. We know that changing behavior is often a complex task. We have learned from this crisis that physical distancing is one such complex behavior that some struggle to adopt.

    As we continue to navigate this new reality, having an understanding of theories and models that influence behavior change will be critical for assessment, as well as for development and implementation of prevention efforts.

Jeff Driskell, PhD, LICSW, is a professor of social work at Salem State University in Salem, MA.