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The Global Handwashing Partnership

Norms, nudges, or addiction? Understanding drivers for handwashing behavior change.

September 20, 2017

Handwashing with soap is one of the most effective ways to prevent diseases, but behavior change to increase handwashing remains a challenge. On September 12, 2017, the Global Handwashing Partnership and USAID hosted a webinar that focused on behavior change approaches for handwashing with soap. The webinar gave participants ideas and perspectives to use on Global Handwashing Day and throughout the year.

During this webinar, Dr. Reshmaan Hussam, Assistant Professor of Business Administration at Harvard Business School, presented key takeaways from an experiment in India exploring the role of habit formation in increasing handwashing rates, as well as a novel technology to measure handwashing behavior. Then, Prof. Dr. Hans Mosler, a Professor of Social Psychology at the University of Zurich and the Group Leader for Environmental and Health Psychology at EAWAG, discussed the RANAS model and how it was used to change handwashing behavior among schoolchildren and caregivers in Zimbabwe. Nga Kim Nguyen, Senior WASH and Social Behavior Change Adviser at USAID, moderated the webinar and facilitated an active discussion to help participants apply these results and ideas for formative research, program design, and more.

Handwashing and Habit Formation: A Theory of Behavioral Change

Dr. Reshmaan Hussam discussed the use of nudges and rational habit theory as applied to handwashing behavior at the critical moment just before preparing food or eating. Motivated by evidence on the habitual nature of handwashing, Dr. Reshmaan and her colleagues conducted a randomized parallel field experiment that sought to understand the main predictors and drivers of the rational habit formation.¹

The study took place across 105 villages in Birbhum District of West Bengal in India, targeting a population of 2,943 peri-urban and rural households. Handwashing was measured by a soap dispenser embedded with time-stamped sensor. Participants received either monitoring of handwashing behavior or incentives for daily handwashing. Villages were categorized into two groups: one group received incentives, and the other received feedback based on monitoring of their handwashing behavior. While sub-groups received different amounts of monitoring and incentives, all were shown to increase handwashing behavior.

The study found that both monitoring and incentives increased handwashing when compared to groups that only received a dispenser; that these effects persisted after monitoring or incentives were removed. The study found that the anticipation of monitoring increased handwashing rates significantly, implying that individuals internalize the habitual nature of handwashing and intentionally develop the habit. The results were consistent with the key predictions of the rational addiction model, expanding its relevance to settings beyond what are usually considered ‘addictive’ or habitual behaviors.

Dr. Hussam highlighted that handwashing alone does have substantial impacts on child health, and that both financial and social incentives were shown to increase handwashing. Drawing on the broader lessons of habitual formation, she suggested that front-loading incentives at the beginning of a handwashing promotion can have persistent effects later on and that anticipating a future increase can increase one’s likelihood of hand washing today.

Read Dr. Reshmaan Hussam and her colleague’s research paper, Habit Formation and Rational Addiction: A Field Experiment in Handwashing. View her presentation to learn more.

Systematic Behaviour Change using the RANAS approach: Handwashing campaign in rural and urban Zimbabwe

Dr. Hans Mosler presented on the application of the RANAS model, which assesses risks, attitudes, norms, abilities, and self‐regulation around behaviors. The RANAS model is used to understand how to motivate individuals to change their behavior based on perceived social pressure, beliefs about cost and benefits of a behavior, and other behavioral factors.

Dr. Mosler discussed the importance of understanding differences between doers and non-doers of a given behavior, as well as identifying and measuring the behavioral factors between those two groups. This allows programs to select behavior change techniques that will be most likely to influence behavior change. The RANAS systematic behavior change approach consists of four phases: 1) Identifying behavioral factors, 2) measuring and determining the behavioral factors via doer/non-doer analysis, 3) selecting appropriate behavior change techniques, and 4) developing strategies to bring behavior change to scale. This systems approach, Dr. Mosler asserted, can enable effective design and implementation of behavior change programs, while allowing for monitoring and evaluation of the change in psychosocial factors and ultimately behavior.

Dr. Mosler and his colleagues conducted a qualitative survey in Harare and the rural province of Masvingo, Zimbabwe, in which they collected information on psychosocial and contextual factors that influence behavior, which was adapted to the RANAS model. The standardized questionnaire measured self-reported handwashing behavior; the understanding of the vulnerability and severity of diarrhea and the impact of health knowledge of handwashing with soap; norms, attitudes and beliefs about handwashing. Based on the information collected, the researchers performed a doer/non-doer analysis.²

When comparing the results of the questionnaire, the researchers found that perceived effort showed too low of difference between doers and non-doers to justify an intervention, but there was a greater difference in perception of others’ approval. Researchers identified this as a key lever for behavior change in this context. Based on this analysis, they designed a program that led to a change in observed handwashing with soap behavior by nearly 40%, as well as an observed change in the psychosocial factors targeted. Dr. Mosler concluded that systematic behavior change using the RANAS approach enables: determination of the behavioral factors to be changed, selection of corresponding behavior change strategies, and appropriate program development.

Read this practical guideline to learn more about the RANAS approach and visit the EAWAG website for case studies, methodological fact sheets, and how to use theory and evidence-based programs to effectively change behavior. You can view Dr. Mosler’s presentation here.

Resources for Handwashing Behavior Change

Learn more about the key takeaways from these presenters and their research by watching a recording of this webinar here. For more tools, case studies, and news, visit GlobalWaters.org and the GHP resources webpage. Finally, Global Handwashing Day is an ideal opportunity to promote handwashing with soap. Find tools and ideas for your celebration at www.GlobalHandwashingDay.org.

For additional reading on the work presented in the webinar, please refer to the following:

  1. Hussam et al. Habit Formation and Rational Addiction: A Field Experiment in Handwashing. 2016, Dec 13. https://economics.mit.edu/files/12512
  2. Seimetz et al. Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe. BMC Res Notes, 2017; 10:280.

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