Eawag: Swiss Federal Institute of Aquatic Science and Technology
Evaluation of a handwashing awareness raising campaign in India
The effect of “The Great WASH Yatra”on handwashing with soap
Elisabeth SeimetzHans-Joachim Mosler
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Crucial behavior to the reduction of diarrheal diseasesHandwashing with soap
o Each year, 760.000 children under the age of five die due to diarrheal diseases(WHO, 2013)
o Diarrhea is the second leading cause of death among children under five in developing countries (Bryce, Boschi-Pinto, Shibuya, & Black, 2005; Walker et al., 2013)
o Handwashing with soap at key moments can cut diarrhea risk by almost half(Cairncross et al., 2010; Curtis & Cairncross, 2003 )
o Handwashing with soap is a rather simple and cost-effective task with a high protective effect (Curtis et al., 2000; Curtis et al., 2011)
o Despite its protective effect, handwashing with soap is practiced at surprisingly low rates(Scott, Curtis, & Rabie, 2003)
o Multi-channel mega-awareness traveling campaign
o Playful promotion of life-saving handwashing behavior
o Focus on the positive power of Cricket and Bollywood
Nirmal Bharat YatraThe Great WASH Yatra
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The Great WASH YatraNirmal Bharat Yatra
Wardha, MaharashtraIndore, Madhya PradeshKota, RajasthanGwalior, Madhya PradeshGorakhpur, Uttar PradeshBettiah, Bihar
Developed by:
Primary funding: Swiss Agency for Development and Cooperation (SDC)
• 2’000 km• 5 Indian states• 6 location• From 2 October until 19 November 2012
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Games and activitiesThe Great WASH Yatra
Stall based games Arena games Sports based games
Labs On stage Exhibitions
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Integration of various elements from theories of behavior change:
o Health belief modelRosenstock, 1974
o Theory of Planned BehaviourAjzen, 1991
o Health Action Process ApproachSchwarzer, 2008
RANAS model of behavior change (Mosler, 2012)Theoretical Background of the Evaluation Study
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Classification of the behavioral determinants into five factor blocks:
Risk Perceived vulnerability – Perceived Severity – Factual knowledge
Attitude Instrumental beliefs – Affective beliefs
Norm Descriptive norm – Injunctive norm
Ability Action knowledge – Action self-efficacy – Maintenance self-efficacy
Self-regulation Action Planning – Coping Planning – Remembering – Commitment
Identification of the Behavioral DeterminantsRANAS model of behavior change (Mosler, 2012)
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Behavioral determinants
BehaviorIntervention
Evaluation of “The Great WASH Yatra”Assessing the effect of the intervention
Risk
Yatra visit
Attitude
Norm
Ability
Self-regulation
Handwashing with soap and water
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Target group: primary caregivers within a household with a child below 5 years
o Structured face to face interviews of 30-40 minutes
o Structured observations of three hours
The same caregivers were surveyed before and after the campaign
Household surveys before and after the campaignEvaluation of “The Great WASH Yatra”
Interviews: N = 1145
Observations: N = 186
Baseline survey
Interviews: N = 990 (86%) 139 Yatra visitors
Observations: N = 139 (75%) 17 Yatra visitors
Follow-up survey
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Visitors Non-visitors1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
4.494.24
4.51 4.45
Stool related handwashing
BaselineFollow-up
Evaluation of “The Great WASH Yatra”Handwashing rates before and after the campaign
Stool related- After using the toilet- After wiping a child’s bottom- After other kinds of contact with stools
No significant increase in the visitors and in the non-visitors group
Self-reported handwashing
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Visitors Non-visitors1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
2.96 2.91
3.81
3.43
Food related handwashing
BaselineFollow-up
Evaluation of “The Great WASH Yatra”Handwashing rates before and after the campaign
Food related- Before cooking- Before eating- Before handling drinking water- Before feeding a child
Significant increases in the visitors and in the non-visitors group (p < .001)
Significant difference between the increases in the visitors and the non-visitors group (p = .021)
Self-reported handwashing
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Changes in risk perceptions
Changes in attitudes
Changes in norms
Changes in abilities
Changes in self-regulation
“The Great WASH Yatra”: Mediating EffectsMediation model: Association between a visit to the Yatra, changes in behavioral determinants and changes in food related handwashing with soap
Perceived severity
Yatra visit
Instrumental beliefs
Descriptive norm
Action self-efficacy
Action control
Changes in food related
handwashingwith soap
Health knowledge
Affective beliefs
Injunctive norm
Maintenance self-efficacy
Remembering
Perceived vulnerability
Commitment
Path values are standardized regression coefficients. The original scales range from 1 to 5.Only significant coefficients with p < .05 are displayed. N = 990.
Adj. R2 = .60
Direct effect n.s.
0.43
0.53
0.14
0.34
0.06
0.27
0.16
0.20
0.45
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Instrumental beliefs
Descriptive norm
Action self-efficacy
Action control
Injunctive norm
Maintenance self-efficacy
Remembering
Perceived severity
Changes in risk perceptions
Changes in attitudes
Changes in norms
Changes in abilities
Changes in self-regulation
“The Great WASH Yatra”: Mediating Effects
Health knowledge
Affective beliefs
Perceived vulnerability
Commitment
Mediation model: significant indirect effects
Changes in food related
handwashingwith soap
Yatra visit
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Instrumental beliefs
Descriptive norm
Action self-efficacy
Action control
Injunctive norm
Maintenance self-efficacy
Remembering
Perceived severity
Changes in risk perceptions
Changes in attitudes
Changes in norms
Changes in abilities
Changes in self-regulation
“The Great WASH Yatra”: Mediating Effects
Health knowledge
Affective beliefs
Perceived vulnerability
Commitment
Mediation model: significant indirect effects
Changes im essensbezogenen Händewaschen mit
SeifeYatra visit
BC 95% CI
Coefficient SE LL UL
0.025 0.014 0.006 0.063
0.033 0.020 0.002 0.081
0.022 0.017 0.001 0.069
0.156 0.057 0.053 0.281
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ConclusionsEvaluation of “The Great WASH Yatra”
No increase in either group
Stool related handwashing behavior
Higher increase in the visitors group
Higher increase can be explained through a higher increase in several behavioral determinants:• Perceived vulnerability• Health knowledge• Affective beliefs• Commitment
Food related handwashing behavior