The importance of handwashing

Diarrhea is the main cause of death in children under the age of five worldwide. The most effective preventive measure for diarrhea is handwashing by the primary caregivers, especially after giving food or potential contact with stool. In most developing countries (and even many developed countries) this remains a challenge. Health promoting agencies therefore focus mainly on the development and implementation of handwashing programs. The effectiveness of these programs is increased when they are based on multiple behavioral theories.

RANAS

RANAS is the Risk, Attitudes, Norms, Abilities, Self-Regulation approach, a multi-theoretical framework to design water, sanitation and hygiene (WaSH) interventions in developing countries. The RANAS approach uses quantitative identification of the social-cognitive factors that determine the key behavior in the target population, and selects behavior change techniques (BCTs) expected to target exactly these factors for intervention development. In a study in Ethiopia, the following determinants of handwashing were found:

• The descriptive norm: behaviors typically practiced by and therefore copied from others.
• The injunctive norm: behaviors typically approved or disapproved of by others.
• Impediments: anticipated barriers and distractions to a behavior.
• Forgetting: forgetting to execute a behavior at a specific time or situation.
• Inconvenience of the present handwashing technique.

The BCTs selected to target these factors were public commitment, facilitating resources, and reminders. These proved far more effective than a standard education intervention, showing that using theory-based interventions is indeed preferable.

Mechanisms of change

A public commitment (making a promise to oneself or the public) is linked to an increase in commitment strength and the injunctive norm. In addition, seeing others commit should affect the descriptive norm. Public commitment should also serve as a reminder, to counter forgetting. Impediments can be decreased by providing resources, such as installing a handwashing station and making water and soap more easily accessible. Using the handwashing infrastructure provided should lead to increased motivational and volitional self-efficacy. This is the belief that one is able to initiate and execute the behavior and the belief in one’s capability to maintain the behavior and recover from relapse. Time and energy already invested by the household should serve to create more commitment to using the handwashing stations by enhancing the injunctive norm. Because they are constructed in public areas, the descriptive norm should also be enhanced. The authors of this article set out to test these assumptions in southern Ethiopia.

Research design

This article tested the change processes of two handwashing interventions, a public commitment intervention with reminder and an infrastructure promotion intervention with reminder. These conditions were compared to an education-only intervention. The interventions were developed to be theory-based and tailored to the target population.

Effectiveness of the interventions

Infrastructure-promotion with reminder and education, alone and in combination with public commitment with reminder, largely predicted changes in social-cognitive factors as expected. The interventions’ effects on handwashing were mediated by these social-cognitive factors. Motivational self-efficacy and social norms were enhanced, while impediments and forgetting were decreased.

Volitional self-efficacy

However, volitional self-efficacy was only affected by infrastructure-promotion with reminder in combination with public commitment. It is possible that the public commitment bolstered the infrastructure-promotion’s effect on volitional self-efficacy.

Food-related versus stool-related commitment strength

It seems that only food-related commitment strength, but not stool-related commitment strength, was affected by the interventions. This shows that these two types of commitment strength should be considered separately when designing an intervention.

Injunctive norm and commitment strength

Public commitment with reminder did not increase the injunctive norm and commitment strength. This difference may have been caused by the subjects not having to read their intentions to the group, but only pledge for themselves. The effect of the reminder in the form of the commitment sign (a headscarf) was also not found, likely because the subjects also forgot to wear the headscarf since they were not accustomed to it. When developing an intervention, the commitment signs need to be designed to ensure that they are made public and are seen as a request to engage in the target behavior.

Conclusion

This study shows that theory-based population-tailored interventions are more successful in changing handwashing than a standard education intervention. The interventions that were used successfully changed the critical social-cognitive factors in the target population. This emphasizes the importance of investigating interventions’ underlying change processes.

BulletPoints

• Diarrhea is the main cause of death in children under the age of five worldwide. The most effective preventive measure for diarrhea is handwashing by the primary caregivers, especially after giving food or potential contact with stool.
• RANAS is the Risk, Attitudes, Norms, Abilities, Self-Regulation approach, a multi-theoretical framework to design water, sanitation and hygiene (WaSH) interventions in developing countries. The RANAS approach uses quantitative identification of the social-cognitive factors that determine the key behavior in the target population, and selects behavior change techniques (BCTs) expected to target exactly these factors for intervention development.
• This study shows that theory-based population-tailored interventions are more successful in changing handwashing than a standard education intervention. The interventions that were used successfully changed the critical social-cognitive factors in the target population. This emphasizes the importance of investigating interventions’ underlying change processes.