An analysis of a unique "SuperMum" (SuperAmma, www.superamma.org) 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 behavior, and could in turn help to reduce the risk of infectious diseases.
An evaluation of the behavior-change intervention, published in The Lancet Global Health journal, shows that 6 months after the campaign was rolled out in 14 villages in rural India, rates of handwashing with soap increased by 31%, compared to communities without the programme, and were sustained for 12 months.
"Every year, diarrhea kills around 800000 children under 5 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 & Tropical Medicine, UK.
"Handwashing campaigns usually try to educate people with health messages about germs and diseases, but so far efforts to change handwashing behavior on a large scale have had little success. Understanding the motivating factors for routine hand washing is essential to any initiative likely to achieve lasting behavior change."
In this cluster-randomised community trial, researchers from the London School of Hygiene & Tropical Medicine 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 behavioral change.
The intervention adapted an open access global toolkit developed by the same team (www.ChooseSoap.org), and targeted emotional drivers found to be the most effective levers for behavior 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 a population 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, 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 (6 weeks, 6 months, and 1 year after the intervention).
At the start of the study, handwashing with soap was rare in both the intervention and control groups (1% vs 2%). After 6 weeks, handwashing was more common in the intervention group (19% vs 4%), and after 6 months, compliance in the intervention group had increased to 37% compared with 6% 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%).
According to study co-author Katie Greenland, from The London School of Hygiene & Tropical Medicine, UK, "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 behavioral 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 behavior change campaigns designed along the lines of our approach."
In a linked Comment, 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."
- Adam Biran, Wolf-Peter Schmidt, Kiruba Sankar Varadharajan, Divya Rajaraman, Raja Kumar, Katie Greenland, Balaji Gopalan, Robert Aunger, Val Curtis. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. The Lancet Global Health, 2014; 2 (3): e145 DOI: 10.1016/S2214-109X(13)70160-8
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