Changing handwashing behavior in southern Ethiopia through infrastructural and commitment interventions
Regular handwashing is the single most effective prevention against diarrheal disease. However, handwashing rates are low in many developing countries, including Ethiopia. A handwashing promotion project in the Borena Zone of southern Ethiopia aimed to increase handwashing rates in communities through systematic behavior change strategies. The strategies applied, especially the tippy tap promotion, proved to be more effective than a standard educational approach: 95% of intervention households were successfully motivated to construct a tippy tap. Three months after the intervention had ended, water and soap were present at the tippy tap in 50% - 80% of the households.
Context Handwashing with soap efficiently prevents diarrhea, one of the leading causes of disease burden globally. As in many other developing countries, handwashing rates are low in Ethiopia. Increased handwashing rates are thus the goal of many hygiene projects run by governmental and non-governmental organizations. However, the effectiveness of these projects has seldom been verified. It is expected that systematic behavior change strategies are more effective than standard approaches, which have often been limited to awareness-raising and knowledge transfer.
Objectives The main goal of this project was to promote handwashing with soap at key times in a rural area in southern Ethiopia by means of systematic behavior change strategies. Specific objectives were:
To assess current handwashing practices and the behavioral factors determining these practices.
To design, implement, and evaluate systematic behavior change strategies to promote handwashing.
Activities Step 1 & 2: Identify, measure, and determine behavioral factors of handwashing:
Qualitative research was conducted to identify potential behavioral factors.
A baseline survey on handwashing practices and behavioral determinants of handwashing was conducted in 462 households in February and March 2012.
The behavioral factors influencing handwashing were specified by means of regression analyses. These were others’ behavior and others’ approval, confidence in performance, continuation and recovering, and impediments. In addition, observations suggested that a lack of handwashing infrastructure and forgetting to wash hands were major constraints on regular handwashing.
Step 3: Select behavior change techniques (BCTs) and design behavior change strategies to promote handwashing:
Three BCTs expected to promote the key factors of handwashing were selected. These were (1) using memory aids and environmental prompts, (2) providing infrastructure, and (3) prompting public commitment.
The BCTs were combined in two behavior change strategies, a tippy tap promotion and a public commitment session, and implemented in combination with a standard education approach.
Step 4: Implement and evaluate behavior change strategies:
The strategies’ effectiveness was assessed through a before-after control trial.
The behavior change strategies were implemented in three intervention villages by the local non-governmental organization, the Gayo Pastoral Development Initiative.
The strategies were compared to a control village that only received the standard education approach (an f-diagram exercise).
A follow-up survey on handwashing practices, behavioral determinants and the strategies’ evaluation was conducted in 514 households in February and March 2013.
95% of intervention households were successfully motivated to construct a tippy tap.
Three months after the intervention had ended, water and soap were present at the tippy tap in 50% - 80% of the households.
The systematic behavior change strategies, and especially the tippy tap promotion, changed behavior more successfully than the standard education approach.
This was because they successfully changed the critical behavioral factors of handwashing, especially others’ behavior, impediments, and remembering.
Conclusion To increase effectiveness, handwashing interventions should be based on theory and driven by data.
Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions
Improved hand hygiene efficiently prevents the major killers of children under the age of five years in Ethiopia and globally, namely diarrhoeal and respiratory diseases. Effective handwashing interventions are thus in great demand. Evidence- and theory-based interventions, especially when matched to the target population's needs, are expected to perform better than common practice. To test this hypothesis, we selected two interventions drawing on a baseline questionnaire-study that applied the RANAS (Risk, Attitudes, Norms, Abilities, Self-regulation) approach and focused on the primary caregivers of households in four rural, water-scarce kebeles (smallest administrative units of Ethiopia) in southern Ethiopia (N=462). The two interventions were tested in combination with a standard education intervention in a quasi-experiment, as follows: kebele 1, education intervention, namely an f-diagram exercise, (n=23); kebele 2, education intervention and public-commitment (n=122); kebele 3, education intervention and tippy-tap-promotion (i.e. handwashing-station-promotion; n=150); kebele 4, education intervention, public-commitment and tippy-tap-promotion (n=113). In kebeles 3 and 4, nearly 100% of the households followed the promotion and invested material and time to construct for themselves a tippy-tap. Three months after intervention termination, the tippy-taps were in use with water and soap being present in up to 83% of the households (kebele 4). Pre-post data analysis on self-reported handwashing revealed that the population-tailored interventions, and especially the tippy-tap-promotion, performed better than the standard education intervention. Tendencies in observed behaviour and a recently developed implicit self-measure pointed to similar results. Changing people's hand hygiene is known to be a challenging task, especially in a water-scarce environment. The present project suggests not only to apply theory and evidence to improve handwashing interventions' effectiveness, but also emphasizes the relevance of tailoring interventions to the target population.
Social-cognitive factors mediating intervention effects on handwashing: a longitudinal study
Handwashing with soap effectively prevents diarrhoea, a leading cause of death in infants. Theory-based interventions are expected to promote handwashing more successfully than standard approaches. The present article investigates the underlying change processes of theory-based handwashing interventions. A nonrandomised field study compared a standard approach to two theory-based interventions that were tailored to the target population, the inhabitants of four villages in southern Ethiopia (N = 408). Data were collected before and after interventions by structured interviews and analysed by mediation analysis. In comparison to the standard approach (i.e., education only), education with public commitment and reminder was slightly more effective in changing social-cognitive factors and handwashing. Education with an infrastructure promotion and reminder was most effective in promoting handwashing through enhancing social-cognitive factors. The results confirm the relevance of testing interventions' underlying change processes.
Identifying the psychological determinants of handwashing: results from two cross-sectional questionnaire studies in Haiti and Ethiopia
Background: Diarrheal disease kills around 760,000 infants every year. Many of these deaths could have been prevented by handwashing with soap. However, the whole range of psychological factors encouraging handwashing is not yet identified and handwashing campaigns are often limited to awareness-raising and education. The purpose of this article was to identify the psychological determinants of handwashing in Haiti (study 1) and Ethiopia (study 2). Methods: Data were collected cross-sectionally by administering face-to-face interviews with the primary caregiver in a participating household (NHaiti = 811; NEthiopia = 463). Hierarchical multiple regression analyses were performed on self-reported handwashing. Results: In both countries, risk factors—meaning awareness and health knowledge—accounted for only 11%-19% of variance in handwashing and were not consistently associated with handwashing. The inclusion of additional factor-groups, namely attitude, norm, ability, and self-regulation factors, led to significant increases in explained variance (P ≤ .01), accounting for 25%-44% of additionally explained variance. The attitude factor disgust, the norm factor, the ability factors motivational self-efficacy and perceived impediments, and the self-regulation factors coping planning and commitment emerged as especially relevant. Conclusions: Handwashing campaigns should focus especially on attitudes and norms and not only on risk.
Contzen, N.; Mosler, H.-J. (2015) Identifying the psychological determinants of handwashing: results from two cross-sectional questionnaire studies in Haiti and Ethiopia, American Journal of Infection Control, 43(8), 826-832, doi:10.1016/j.ajic.2015.04.186, Institutional Repository