Increasing handwashing with soap: emotional drivers or social norms?
Authors: Elli Leontsini, Peter J Winch
Journal: The Lancet Global Health (2014)

It is good to see any cluster-randomised community trial of a handwashing intervention, much more a successful one. Globally there is considerable funding invested in handwashing promotion, yet the kind of rigorous study published in this month's issue of The Lancet Global Health by Adam Biran and colleagues1Biran A Schmidt W-P Varadharajan KS et al.Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial.Lancet Glob Health. 2014; 2: e145-e154Summary Full Text Full Text PDF Scopus (163) Google Scholar is rare in the literature. As rare are the implementation details provided, which are often lacking from publications focused on results. Yet such details are important for those seeking to replicate or scale up the intervention. Assessment of study outcomes through structured observation is another laudable aspect of the study method. However, we wonder whether the mechanism of action of the behavioural intervention was different from the mechanism assumed by Biran and colleagues. Although it is plausible that the intervention acted on the intended emotional drivers of handwashing (nurture, disgust, affiliation, status), which in turn resulted in increased uptake of handwashing, these determinants were not measured. Members of Biran and colleagues' research team have previously systematically measured these determinants in Kenya.2Aunger R Schmidt W-P Ranpura A et al.Three kinds of psychological determinants for hand-washing behaviour in Kenya.Soc Sci Med. 2010; 70: 383-391Crossref PubMed Scopus (76) Google Scholar Yet it is possible that the changes observed in this study occurred through a different pathway. An alternative explanation would be that the implementing team created ideal conditions for formation of new habits: a break in the routine, cues to perform the new behaviour, promotion of new social norms, creation of a stable context for practising the behaviour, and exhortation to practise the new behaviour repeatedly.3Wood W Quinn JM Kashy DA Habits in everyday life: thought, emotion, and action.J Pers Soc Psychol. 2002; 83: 1281-1297Crossref PubMed Scopus (588) Google Scholar The break in the routine and promotion of repeated practice were created by community and school events, and followed by household visits. The stable context for practising the behaviour was evidenced by the fact that every household had soap at baseline, more than 90% of households had access to water within their yards or nearby, and this availability was enhanced by installation of handwashing stations in schools and their monitoring before eating. New social norms were promoted in multiple ways including modelling by village chairmen and group pledgings, and might have persisted beyond the end of the long and short intervention, thus explaining the surprisingly sustained effect over time. Given these favourable conditions for adoption of new habits created by the intervention team, it is possible that significant increases in handwashing uptake would have been achieved even in the absence of message content related to nurture and disgust. Biran and colleagues contend that message content related to "rational health beliefs" does not effectively increase handwashing practice, and indeed this is also long-standing concern in HIV prevention,4Obregon COAR A critical assessment of theories/models used in health communication for HIV/AIDS.J Health Commun. 2000; 5: 5-15Crossref PubMed Scopus (212) Google Scholar although rational health beliefs do appear to be beneficial for smoking.5Nourjah P Wagener DK Eberhardt M Horowitz AM Knowledge of Risk factors and risk behaviors related to coronary heart disease among blue and white collar males.J Public Health Policy. 1994; 15: 443-459Crossref PubMed Scopus (41) Google Scholar A meta-analysis of the effectiveness of constructs in the Health Belief Model in predicting behaviour found that "the relationship between susceptibility beliefs and behaviour was almost always near zero".6Carpenter CJ A meta-analysis of the effectiveness of health belief model variables in predicting behavior.Health Commun. 2010; 25: 661-669Crossref PubMed Scopus (691) Google Scholar This finding, combined with some of Biran and colleagues' previous work on disgust,7Judah G Aunger R Schmidt W-P Michie S Granger S Curtis V Experimental pretesting of hand-washing interventions in a natural setting.Am J Public Health. 2009; 99: S405-S411Crossref PubMed Scopus (129) Google Scholar strengthens the rationale for a focus on emotions (nurture and disgust) in this study. Interestingly, the previous study indicated a significant effect of disgust on handwashing for men but not women.7Judah G Aunger R Schmidt W-P Michie S Granger S Curtis V Experimental pretesting of hand-washing interventions in a natural setting.Am J Public Health. 2009; 99: S405-S411Crossref PubMed Scopus (129) Google Scholar It would be illuminating in a future study to have two different intervention groups: one with the optimum conditions for formation of new habits mentioned above but without the content related to emotions (nurture and disgust), and the other with the full intervention that was tested. So although the argument for disgust as a key motivator for handwashing is intriguing,8Curtis V de Barra M Aunger R Disgust as an adaptive system for disease avoidance behaviour.Philos Trans R Soc Lond B Biol Sci. 2011; 366: 389-401Crossref PubMed Scopus (413) Google Scholar further research is needed to provide definitive evidence of its effectiveness. We view affiliation, social norms, and status as motives differing from emotions,9Aunger R Curtis V The anatomy of motivation: an evolutionary-ecological approach.Biol Theory. 2013; 8: 49-63Crossref Scopus (55) Google Scholar and are unclear whether they are core components of a package of emotion-related interventions. Finally, the level of handwashing uptake achieved for key occasions post-intervention was comparable to that of other studies—eg, by Huda and colleagues10Huda TM Unicomb L Johnston RB Halder AK Yushuf Sharker MA Luby SP Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh.Soc Sci Med. 2012; 75: 604-611Crossref PubMed Scopus (91) Google Scholar—and might not be high enough to have an effect on public health. Creation of a more enabling environment by means of multiple conveniently placed and replenished handwashing stations in and around the home11Devine J Beyond tippy-taps: the role of enabling products in scaling up and sustaining handwashing.Waterlines. 2010; 29: 304Crossref Scopus (18) Google Scholar might be needed to achieve a higher, more effective, increase in handwashing with soap at key occasions. We declare that we have no competing interests. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trialThis study shows that substantial increases in handwashing with soap can be achieved using a scalable intervention based on emotional drivers. Full-Text PDF Open Access