NGO’s behavioral change approach to encourage sustainable hand-hygiene interventions

By Purva Jain*

Handwashing is a simple act, yet so often neglected. Of all hygiene practices, handwashing with soap is a top priority and the most cost-effective way of preventing global infectious diseases like diarrhoea and pneumonia, which are leading causes of child mortality in the world (Jamison, 2006). As per a WHO report, more than 800 children under age five die every day from diarrhoeal diseases due to poor sanitation, poor hygiene, or unsafe drinking water. Pneumonia accounts for 15 percent of all deaths of children under five. As the implications of the COVID-19 pandemic sweep across the world, the sustainable adoption of a good hand-washing habit has become an indispensable way to prevent infectious disease. However, per a UNICEF report, approximately two of five people across the globe do not have basic hand-washing facilities with soap and water available at home, 1.6 billion have limited facilities lacking soap or water, and 1.4 billion have no facility at all.

The situation in India in the area of health and hygiene is not very encouraging. Per a NSS report published in 2018, only 74 percent of people in India wash their hands after defecation and only 36 percent wash hands before eating. The majority prefer washing hands with only water. Many people in India don’t wash their hands because they believe that hands that look clean cannot make them sick. This lack of healthy hand hygiene practices increases the vulnerability to various infectious diseases.

The government has consistently worked toward safe hygiene and sanitation practices. The inception and success of many universal programs and campaigns, such as Swachh Bharat Mission, WASH (Water, Sanitation, and Hygiene), Lifebuoy and Dettol hand-washing campaigns, Swachh Vidyalaya Swachh Bharat campaign, and designating 15 October as Global Hand-washing day, have contributed to raising awareness and improved hygiene practices. However, it is quite evident that a knowledge-practice gap still exists among people (Sarkar, 2013; Takalkar, et al., 2013; Biswas, et al., 2015).

A study conducted by Water Aid India in the villages of four states, Bihar, Chhattisgarh, Rajasthan and Odisha in 2017, reported consistency in high levels of awareness with behavioral practices of hand-washing with soap and water, particularly after defecation and before eating. Monitoring hand-washing behavior is difficult, but the observation of having a designated place with water and soap in households is a robust proxy indicator. Observations of the toilet and kitchen areas showed that handwashing may be challenging given the lack of soap and water at these locations. Among mothers or caregivers, hand hygiene behaviors and associated knowledge are poor. They may be more likely to wash their hands after washing the child’s bottom or disposing a child’s faeces. Yet these hand-hygiene practices do not extend to infant and young children’s feeding food practices.

Having little understanding of the importance of hygiene and sanitation practices, a lack of WASH infrastructure, traditional knowledge, poverty, ignorance, and lack of will are all factors that impede behavioral changes. Attitude plays a definitive role as well. These impeding factors are the biggest hindrance to the transformation of hygiene-related knowledge into practice and practice into habit (Akter and Ali, 2014).

Bridging the gap between knowledge and practice

The traditional approaches of promoting hand-wash practices through posters, leaflets, meetings, events, or focus group discussion in the Millennium Development Goal (MDG) era haven’t worked to bring positive changes. Public health practitioners increasingly agree that it is not enough to provide training and educational interventions to create awareness. Ensuring behaviour change is necessary at the same time. Current goal has shifted to the sustainable adoption of good hand-washing practices. Through Goal 6 of UN Sustainable Development Goals, ensure availability and sustainable management of water and sanitation for all, the government is committed to promoting the importance of hand-washing with soap.

Changing behavior is often necessary to tackle any problems. Sustained behavior change requires more than just communication. It is also necessary to leverage emotional drive, as seen from the Super Amma trial in Andhra Pradesh where communication concepts were designed based on nurture, disgust, affiliation, and status as motivational drivers of handwashing. (Mathew, et al., 2015). Unilever has also come up with an innovative behavioral change approach, five Levers for Change: make it a habit, make it understood, make it rewarding, make it desirable, and make it easy. This set of behaviour change principles, if applied to behavior change interventions, will increase the likelihood of having a lasting impact. They are based on three types of Insights: what can stop change (barriers), what helps to start change (triggers), and what helps to sustain change (motivators) (Unilever, 2012). The Lifebuoy “Help a child reach 5 campaign,” has also promoted creative films. Gondappa, Tree of Life, Chamki, and Sherry share personal, powerful, and real perspectives on the individual tragedy of losing a child to preventable infections like diarrhoea and pneumonia, and they advocate hand-washing practices. Showing such films is also effective because they engage all the senses, which deepen one’s understanding.

Reaching out to children is very crucial to create the habits of handwashing. The mindset change is only possible if children are sensitized about good hygiene practices during their formative years. It is necessary to incorporate dialogues, conversation, and activities such as organizing short films screenings, school plays, wall paintings, and inculcating the habit of washing hands before meals to reinforce good hygiene practices in schools. To encourage handwashing, “nudges” can be introduced in school settings. Nudges influence behavior in an encouraging direction without changing the values of people. In a research study by Dreibelbis (2016), nudges were introduced to encourage handwashing with soap among primary school students in Bangladesh. In two schools, handwashing stations were built in visible and easy‐to‐reach locations, brightly colored paths were painted from toilets to the handwashing stations, and footprints and handprints were painted on the path and the handwashing station. Hand-washing with soap after using the toilet went from 4 percent before these nudges were created, to 74 percent six weeks after nudges were introduced. No other hygiene education was provided as part of the study. This is a compelling example of how nudges can be applied to bring desired behavioral change.

Behavior change is a difficult process. The rising COVID-19 emergency is said to offer hope for spurring the government to take hygiene-related interventions seriously and spur people themselves to change their habits in ways that will bring lasting behavioral change. It is time to build behavioral change policies based on what has worked so far. Designing creative and innovative strategies based on emotional drivers such as nurture, disgust, affiliation, comfort, inspiration, and status (SuperAma campaign), placement of visual cues, innovative marketing, MINDSPACE, nudges, participatory approaches, and other approaches to behavior change provide useful pointers to core behavior change techniques. Making key strategic shifts in WASH-related policies and programs by focusing on such behavior-change approaches can strengthen hygiene-related interventions.

With a challenge to reach 1.37 billion Indian people in the current political, socioeconomic, and technological scenario, the government can leverage its capacity constraints by adopting an approach of partnering with the multilaterals, non-profits, think tanks, industry, academicians, and civil societies to create the changes needed to achieve the UN Sustainable Development Goal of ensuring availability and sustainable management of water and sanitation for all.

*Purva Jain is Research Associate, at S M Sehgal Foundation, a rural development organization, registered in India since 1999

References

Akter, T., and Ali, A.M. 2014. Factors influencing knowledge and practice of hygiene in Water, Sanitation and Hygiene (WASH) programme areas of Bangladesh Rural Advancement Committee.

Biswas, D., Sahoo, S., Dasgupta, A., Preeti, P.S., Kumar, A., and Das, S. 2015. Quantification of Perception Status of Hand Washing Practice Among School Children in a Rural Area of West Bengal. Scholars Journal of Applied Medical Sciences, Vol. 3, Issue 4, 1683–1687.

Dreibelbis R, Kroeger, A., Hossain, K., Venkatesh, M., and Ram, P.K. 2016. Behavior Change without Behavior Change Communication: Nudging handwashing among primary school students in Bangladesh. Int J Environ Res Public Health. 13(1), 129. doi: 10.3390/ijerph13010129.

Jamison, D.T., Breman, J.G., Measham, A.R., Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., and Musgrove, P., eds. 2006. Disease control priorities in developing countries. The World Bank.

Mathew, J.L., Lahariya, C., and Bharti, B. 2014. Effect of a behaviour-change intervention on hand washing with soap in India (SuperAmma): A Cluster-Randomised Trial: Source Citation: Biran A, Schmidt W, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, et al. Lancet Glob Health 2014; 2: E145–54. Indian Pediatrics, 51(5), 393.

National Sample Survey (NSS). 2018. Drinking Water, Sanitation, Hygiene and Housing Condition in India. Ministry of Statistic and Programing Implementation. Government of India. Retrieved from: http://www.mospi.gov.in/sites/default/files/publication_reports/ Report_584_ final_0.pdf.

Sarkar, M. 2013. Personal hygiene among primary school children living in a slum of Kolkata. Journal of Preventive Medicine and Hygiene, Vol. 54, Issue 3, 153–158.

Takalkar, A.A., Nirgude, A.S., Nagaraj, K., Naik, P.R., Prasad, V.G., and Reshmi, S.S. 2013). Hand Hygiene: Perception and Practices of School Going Children from Rural Government Schools of Nalgonda, Andhra Pradesh. Int J Med Health Sci, 2(2-2), 154–160.

Unilever, P.L.C. 2012. Inspiring sustainable living, expert insight into consumer behaviour & Unilever’s Five Levers for change. Retrieved from: https://www.hul.co.in/Images/slp_5-levers-for-change_tcm1255-414399_en.pdf.

Water Aid. 2017. Spotlight on handwashing in rural India. Retrieved from https://www.outlineindia.com/othermedia/1531392037.Hand-hygiene-study.pdf.

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