Step two: Behavior initation
Initiating handwashing behavior is a key component of many handwashing behavior change programs. Unlike some other health behaviors, handwashing has to be performed frequently and consistently to be effective. Even when a person begins to change their behavior to wash their hands more often, it is important to sustain those changes. Achieving sustained handwashing behavior change is a challenge but is essential for people to enjoy the benefits of handwashing with soap.
Brain science can help us understand how to achieve sustained handwashing behavior change. Two different parts of the brain are involved in driving handwashing behavior.
The neocortex is the decision-making part of the brain that initiates behaviors driven by attitudes, intentions, social norms, rational beliefs, and emotions. Often handwashing behavior change programs focus on the neocortex. It is this part of the brain that we seek to engage in initiating handwashing behavior through social norms and emotional motivators, along with environmental cues.
The basal ganglia is the part of the brain that automatically drives behaviors that are determined by habit. This part of the brain does not rely on motivation or decisions, but rather activates handwashing behavior in response to environmental cues, turning handwashing into an automatic long term behavior. Handwashing behavior change programs often fail to activate this brain system, despite the fact that it is the basal ganglia that maintains handwashing behavior in the long term.
Handwashing initiation: The pre-habit steps that drive handwashing with soap
Before handwashing can be turned into a habit, people need to begin the behavior. The following factors can help make this possible:
Social Norms
Social norms are rules that apply to certain situations. They include people’s beliefs about what others do or should do, as well as how they should behave in different situations. For example, a culture might have a social norm that requires guests to remove their shoes when they visit someone’s home. People abide by the rule if others do so and if the same is expected of them. These norms are created and governed by the community. This paper from UNICEF explains more about what social norms are, how to measure them, and examples for how health behavior change is related to social norms.
A norm around handwashing before eating, for example, can help encourage people to wash their hands. In some cases, social norms might discourage people from washing their hands. Social norms can either be leveraged to encourage handwashing or may need to be addressed as a barrier to handwashing. In 2014, the GHP’s Handwashing Behavior Change Think Tank discussed the importance of raising the visibility of handwashing to reinforce hygiene social norms.
Emotional Drivers
Emotional drivers, such as disgust or a desire to nurture and care for others, are powerful motivators and can have a lasting impact on a person’s behavior and the development of good habits. The SuperAmma Campaign is one example of how these drivers have been incorporated into a handwashing promotion campaign. This campaign found that emotional drivers were able to substantially increase handwashing with soap.
Environmental cues
For people to wash their hands they must have access to the so-called determinants of handwashing—a functional handwashing station with soap and water in stable physical locations convenient for the critical moments of handwashing. If handwashing stations are visible, accessible, and situated in an appropriate location, they serve as environmental cues to remind people to wash their hands.
A good location for a handwashing station, for example, would be immediately outside a latrine, so people will see it when they leave the latrine (thus at a critical moment for handwashing) and must walk past it to return to the home.
Handwashing stations are less likely to be used and won’t serve as an environmental cue if they are hidden or not near a location where activities happen that should be associated with handwashing. Environmental cues don’t necessarily have to consist of handwashing stations. They could, for example, include signage reminding people to wash their hands, or eyes painted on a handwashing station to remind people their handwashing behavior is being noticed in the context of handwashing being a positive social norm.
Nudges
Handwashing is often done as a relatively unconscious habitual action, and can be easily triggered by contextual cues, so it may lend itself well to nudging. Nudges are simple cues that influence us to behave in a certain way. The idea of nudges rests on the theory that behavior is not only based on conscious thoughts and decisions, but that it can be unconsciously guided by choice architecture. Choice architecture is the practice of changing the way that options are presented to people, with the intention of influencing their choices. Nudges have been used in marketing and urban planning, and have been tested to encourage healthy behaviors, including handwashing.
While the research base around nudges is still growing, there are some positive examples of use for handwashing. For example, a 2015 study by Dreibelbis et al. tested the idea of using nudges in school settings to improve rates of handwashing with soap after using the toilet. In two schools, handwashing stations were built in visible and easy‐to‐reach locations, brightly colored paths were painted from toilets to the handwashing station, and footprints and handprints were painted on the path and handwashing station. Handwashing with soap after using the toilet went from 4% before these nudges were created, to 74% six weeks after nudges were introduced. Learn more about nudges for handwashing in our FAQ brief.