From Behavior Initiation to Habit Formation
Initiating handwashing behavior is a key component of many handwashing behavior change programs–but unlike many other health interventions, handwashing is not a one-off activity. Handwashing with soap needs to be practiced consistently to be effective. All too often, handwashing behavior change is temporary, and relapse occurs. Achieving sustained handwashing behavior change is one of the great challenges that face those who promote handwashing.
An important approach to achieving sustained handwashing behavior change is applying the science of habit formation.
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, the following factors need to be in place:
Social norms are rules that apply to certain 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. A norm around handwashing before eating, for example, can help convert the practice into a habit. In 2014, the GHP’s Handwashing Behavior Change Think Tank discussed the importance of raising the visibility of handwashing to reinforce hygiene social norms. People are more likely to wash their hands if others may be observing them doing so.
See a presentation addressing social norms and handwashing from the 2014 Handwashing Behavior Change Think Tank here.
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.
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.
Sustaining handwashing: converting handwashing into a habit
Handwashing habit formation means converting handwashing from a behavior that people must think about and decide to undertake (intention and decision making) into a procedure that we automatically undertake in response to cues, without involving the decision-making parts of our brain (habit). When handwashing becomes a habit, social norms, emotional drivers, and other decision making processes take a back seat as the process in the brain evolves from motivation to automation. While there may be a general anticipation of reward, this is diffuse and is not associated with individual handwashing episodes.
There are seven key principles for turning handwashing into a habit, developed by Dr. David Neal. These can be integrated into handwashing behavior change programs to drive handwashing sustainability:
- Supporting Environment: Habits are triggered by environmental cues. To form a handwashing habit, environmental cues must be immediately and consistently available. Having to search for soap and water, for example, require a high level of motivation, rather than facilitating automation.
- Leverage Context: There are key moments where people are particularly open to developing new habits. For example, changes to the physical/action environment, like new motherhood, or starting school, prompt a whole range of new habits, and handwashing can be effectively integrated here. Alternatively, handwashing can ‘piggy back’ on pre-existing habits, for example if people already check their appearance in the mirror, a mirror could be attached to a handwashing station to create an automatic link where one habit cues the other.
- Eliminate Friction: Choice is the enemy of habit. Reducing choice, simplifying actions, and diminishing perceived effort all support habit formation. For example, reduce complexity of handwashing instructions, and ensure easy accessibility.
- Create a cue ecosystem: Cues can trigger handwashing behavior, whether it be posters, colored footsteps on the ground leading from the latrine to the handwashing station, or some other cues, visual or otherwise, customized to local settings.
- Accelerate links between cue and action: Using ‘if x then y’ reminders can be helpful, for example visual reminders like using Glo Germ show people how their hands remain unclean if they don’t wash their hands effectively.
- Intervention through doing: Help form procedural memory not just by explaining how to wash hands, but by actively having people do so, for example group handwashing at school.
- Conscious storytelling: People believing there is a deep and meaningful purpose behind their habits strengthens their habits, for example mothers believing they are keeping their children healthy may prevent relapse and encourage advocacy.
Further information on handwashing and the science of habit
Given the importance of habits to a behavior such as handwashing, the GHP and GHP Steering Committee Partner the USAID/WASHplus Project, co-hosted a webinar on this topic featuring behavioral scientist, Dr. David Neal. Watch this webinar here.