SuperAmma Promoting Handwashing with Soap in Rural India. Adam Biran, Val Curtis, Bob Aunger LSHTM

SuperAmma

Promoting Handwashing with Soap in Rural India.

Adam Biran, Val Curtis, Bob Aunger LSHTM

• Val Curtis• Wolf Schmidt• Bob Aunger• Katie Greenland• Adam Biran

• Kiruba Varadharajan• Divya Rajaraman• Raja Kumar

• Balaji Gopalan

Funded by Wellcome Trustand SHARE

Germs cause disease

Background

Lack of evidence for effectiveness

Increasing recognition of ‘non-rational’ influences

• Formative research in 12+ countries

• Experimental work – UK

–When do people wash hands?–Why do they wash

hands?–What could motivate

handwashing?

The Challenge• Promote handwashing with soap at key times

• No health messages• No mass media

• Potential for scaling up– Small intervention team– Limited contact time

THE INTERVENTION

Active Ingredients• Behaviour drivers–Nurture–Disgust –Norms

• Local role models• Cues and reminders• SuperAmma– Central character

Disgust : what you don’t wash off you eat!

A Day in the Life of a Hand

Animation of daily hand contamination

Social NormsEveryone is doing it...• Pledging ceremony• Stickers on pledged houses

Wall of All

Reminders – for Habit Formation

•Stickers in bathrooms•Children’s report card (2 weeks)

Local Relevance• Posters local people– Important people are doing it

• Video testimonials of local people– People like me are doing it

Nurture• SuperAmma film– A heart-warming taleof maternal love...

and handwashing

Mid-Day MealMoral Stories

School Activities

Poo tag game

Children’s rally

Rewards: Gifts, Certificates, Ceremonies

She wakes up before the sun,

She cleans up everyone,

She brushes my teeth,

Washes my face,

She can cook up a meal

before I can say

My mom is a supermom!

My mom is a supermom!

She washes her hands with soap,

Before idli or before soup,

She combs my hair,

She cuts my nails,

She can get me ready

Before I can say

My mom is a supermom!

My mom is a supermom!

She tells me many good stuff,

Some easy and some tough,

wash my hands with soap after toilet,

Wash my hands with soap before I eat,

but she can do all this and more

Before I can say

My mom is a supermom!

My mom is a supermom!

Jingle

Delivery

• Two mobilisers, 1 technician, 1 driver

• 4 days – 2 consecutive and 2 a week apart

• School and community

events days 1 and 4

THE STUDY

Study Site• Southern Andrhra Pradesh• Village size 300-1500• Water from pumps and standpipes• Soap present in all households• Open defecation

Study Design

• Cluster randomised, controlled trial• 7 village pairs matched on size• 1 village from each pair randomised to receive

intervention• Controls receive nothing• 25 households per village – Random selection from school register

Outcome MeasuresBehaviour change

• Primary outcome– % of key events when hands are washed with soap

• Secondary outcome– % of all handwashes using soap

Data collected by structured observation 05:30 – 08:30At baseline and 3 weeks post-intervention

2% 4%1%

19%

0%

5%

10%

15%

20%

25%

30%

35%

Pre-intervention Post-intervention

Soap use at key events

intervention

control

Difference 16%p= 0.005

hand

was

hing

with

soap

18% 18%19%

36%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Pre-intervention Post-intervention

Han

dwas

hing

with

soa

p

Soap-use for all handwashes

intervention

control

Difference 18%p= 0.001

Normative Beliefs about HWWSIn this village... Intervention Control

almost everyone HWWS before eating

35% 8%

almost everyone HWWS after defecation

36% 10%

People HWWS more than in other villages

98% 42%

Conclusions• Suggests behaviour change can be achieved• Not about health• Creative inputs are important• Still a lot of unwashed hands

For more information visit www.choosesoap.org