A version of this post originally appeared on FHI 360’s R&E Search for Evidence blog.
Evidence on the health and social benefits of handwashing is strong. We know that handwashing can prevent up to 40% of diarrheal diseases, and can lead to fewer school absences and increased economic productivity. However, many people don’t wash their hands at critical times, even when handwashing facilities are available. While research on behavior change has shown examples of approaches that lead to increased rates in handwashing, we’re still seeking to understand why people wash their hands, and how motivation for handwashing can be translated into programs that result in effective behavior change.
In advance of Global Handwashing Day on October 15, USAID and the Global Handwashing Partnership – an international coalition with a Secretariat hosted by FHI 360 – organized a webinar on drivers for handwashing behavior change. The Partnership’s work focuses on promoting handwashing with soap as key to health and development, with an emphasis on connecting practitioners with research findings to inform their work. Our webinar speakers provided two examples of how research is exploring behavior change from cognitive (how we think about and understand handwashing) and automatic (how we can be unconsciously prompted to wash our hands) standpoints. In this blog post, I’ll summarize how the two examples show different ways of understanding human behavior and discuss how the findings help us understand what drives behavior change for handwashing.
In our first research example, Prof. Dr. Hans Mosler, Professor of Social Psychology at the University of Zurich and the Group Leader for Environmental and Health Psychology at EAWAG, presented his work using the RANAS model to determine behavior change approaches for handwashing. The RANAS model looks at individual risks, attitudes, norms, abilities, and self-regulation around behaviors. Mosler and his colleagues developed and implemented a survey on handwashing behavior in rural Zimbabwe that was framed around the elements in the RANAS model. The research team conducted qualitative interviews to understand drivers for barriers to handwashing, including contextual factors like availability of handwashing facilities, and psychosocial factors like social norms or beliefs about the benefits of handwashing.
Qualitative data then informed a quantitative survey, in which ‘doers’ (people who wash their hands at 9 out of 10 recommended times) were compared with ‘non-doers’ (people who wash their hands less often). Each group received an average score for each factor identified in the previous qualitative research. Some factors, like the perceived effort involved in handwashing, were similar for both groups. Others, like others’ approval, had a larger difference between the two groups. This finding led researchers to develop a behavior change program that aimed to increase the perception of consistent handwashing as a social norm and a source of others’ approval. The program led to increased handwashing behavior, with handwashing after defecation increasing by close to 30%, and food-related handwashing increasing by approximately 20%. Perception of others’ approval of handwashing also increased. View Dr. Mosler’s presentation to learn more.
In our second research example, Dr. Reshmaan Hussam presented a randomized control trial that leveraged a different motivation – habit formation and nudging – for handwashing behavior at mealtime. Dr. Hussam and her colleagues based their intervention on the ideas of habit formation, when a behavior becomes easier after repetition, and rational habit formation, in which an individual consciously develops a habit to their own future behavior. The study sample of 2,900 households in rural West Bengal, India, was randomized into incentive and monitoring arms. All households were provided with a dispenser that measured handwashing, a year’s supply of soap, and a calendar to track behavior. Incentive households also received tickets for prizes based on handwashing behavior. Both incentive and monitoring households were further stratified with some groups being told to anticipate additional incentives or monitoring, and some receiving additional monitoring or incentives as a surprise.
Their study found that both incentives and monitoring increased handwashing behavior, with monitoring households increasing handwashing by 23% in the short term, and incentives by 70%. Notably, tripling incentives had only a small additional effect (8%), but households anticipating monitoring had a 39% increase. Among all intervention groups, children had 39.5% fewer days with diarrhea, and 23% fewer days with acute respiratory infections, as well as improved outcomes in weight, height, and arm circumference for age. Though handwashing habits were sustained compared to control groups in both incentive and monitoring arms 140 days after intervention, the study did see a reduction in behavior after the intervention concluded as explained in the study paper.
Both webinar presenters agreed that a major takeaway from their research was the need to understand the community in which behavior change will take place, and cautioned that neither study was intended to be replicated without careful contextualization. These studies shed light on the complex drivers of handwashing behavior, and illuminate two examples of how to use those drivers to develop interventions. While research may never be able to provide a ‘one size fits all’ approach to behavior change, it can shed light on the factors that motivate handwashing and other behaviors.
To watch the webinar, view presentations, and read the articles presented, visit our summary page here. Global Handwashing Day, on October 15th, is an important opportunity to celebrate, promote, and advocate for handwashing with soap. Visit www.globalhandwashingday.org to get involved.