An analysis of a unique handwashing campaign shows for the first time that using emotional motivators, such as feelings of disgust and nurture, rather than health messages, can result in significant, long-lasting improvements in people's handwashing behaviour, and could in turn help to reduce the risk of infectious diseases.
An evaluation of the SuperAmma ('SuperMum') behaviour-change intervention, published in the 'Lancet Global Health' journal, shows that six months after the campaign was rolled out in 14 villages in rural India, rates of handwashing with soap increased by 31 per cent, compared to communities without the programme, and were sustained for 12 months.
"Every year, diarrhoea kills around 800 000 children under five years old. Handwashing with soap could prevent perhaps a third of these deaths," explains study author Dr Val Curtis, from the London School of Hygiene and Tropical Medicine (LSHTM). "Handwashing campaigns usually try to educate people with health messages about germs and diseases, but so far efforts to change handwashing behaviour on a large scale have had little success. Understanding the motivating factors for routine handwashing is essential to any initiative likely to achieve lasting behaviour change."
In this cluster-randomised community trial, researchers from the LSHTM and St John's Research Institute, with communications consultants Centre of Gravity in Bangalore, India, tested whether a scalable village intervention designed to increase handwashing with soap in southern Andhra Pradesh, India, was successful in bringing about behavioural change.
The intervention adapted an open access global toolkit developed by the same team, and targeted emotional drivers found to be the most effective levers for behaviour change: disgust (the desire to avoid and remove contamination), nurture (the desire for a happy, thriving child), status (the desire to have greater access to resources than others), and affiliation (the desire to fit in).
From 57 eligible villages - with populations of 700-2000 people, a state-run primary school and a preschool - 14 villages were selected and randomly assigned to receive the intervention or no intervention. As part of the SuperAmma intervention, promoters put on community and school-based events involving animated films, comic skits, and public pledging ceremonies during which women promised to wash their hands at key occasions and to help ensure their children did the same.
Observed rates of handwashing with soap at key moments (after toilet use, before food handling, or after cleaning a child) were measured in a random sample of 25 households in each village at the start of the study and at three subsequent visits (six weeks, six months, and one year after the intervention).
At the start of the study, handwashing with soap was rare in both the intervention and control groups (1 per cent and 2 per cent respectively). After six weeks, handwashing was more common in the intervention group (19 per cent vs 4 per cent), and after six months, handwashing in the intervention group had increased to 37 per cent compared with 6 per cent in the control group. One year after the campaign, and after the control villages had received a shortened version of the intervention, rates of handwashing with soap were the same in both groups (29 per cent).
According to study co-author Katie Greenland, from the LSHTM, "The SuperAmma campaign appears to be successful because it engages people at a strong emotional level, not just an intellectual level, and that's why the behavioural change was long-lasting. Whether the observed increase in handwashing with soap is sufficient to reduce infection remains unclear, but in view of our promising results, public health practitioners should consider behaviour change campaigns designed along the lines of our approach."
In a linked comment piece, Elli Leontsini and Peter J Winch from Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, caution: "The level of handwashing uptake achieved for key occasions post-intervention was comparable to that of other studies… 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 home might be needed to achieve a higher, more effective, increase in handwashing with soap at key occasions."
This study was funded by the Wellcome Trust and UK aid from the Department of International Development (DFID) as part of the SHARE research programme.
Image: Illustration from the SuperAmma campaign. Credit: Lancet Global Health