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