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 Seimetz Hans-Joachim Mosler

Crucial behavior to the reduction of diarrheal diseases Handwashing with soap 2 o Each year, 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 Yatra The Great WASH Yatra 3

Nirmal Bharat Yatra 4 Wardha, Maharashtra Indore, Madhya Pradesh Kota, Rajasthan Gwalior, Madhya Pradesh Gorakhpur, Uttar Pradesh Bettiah, 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

Games and activities The Great WASH Yatra 5 Stall based gamesArena gamesSports based games LabsOn stageExhibitions

 Integration of various elements from theories of behavior change: o Health belief model Rosenstock, 1974 o Theory of Planned Behaviour Ajzen, 1991 o Health Action Process Approach Schwarzer, 2008 RANAS model of behavior change (Mosler, 2012) Theoretical Background of the Evaluation Study 6

Classification of the behavioral determinants into five factor blocks: RiskPerceived vulnerability – Perceived Severity – Factual knowledge AttitudeInstrumental beliefs – Affective beliefs NormDescriptive norm – Injunctive norm AbilityAction knowledge – Action self-efficacy – Maintenance self-efficacy Self-regulationAction Planning – Coping Planning – Remembering – Commitment Identification of the Behavioral Determinants RANAS model of behavior change (Mosler, 2012) 7

Behavioral determinants BehaviorIntervention Evaluation of “The Great WASH Yatra” Assessing the effect of the intervention 8 Risk Yatra visit Attitude Norm Ability Self-regulation Handwashing with soap and water

 Target group: primary caregivers within a household with a child below 5 years o Structured face to face interviews of minutes o Structured observations of three hours  The same caregivers were surveyed before and after the campaign Household surveys before and after the campaign Evaluation of “The Great WASH Yatra” 9 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

Evaluation of “The Great WASH Yatra” Handwashing rates before and after the campaign 10 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

Evaluation of “The Great WASH Yatra” Handwashing rates before and after the campaign 11 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

Changes in risk perceptions Changes in attitudes Changes in norms Changes in abilities Changes in self-regulation “The Great WASH Yatra”: Mediating Effects Mediation model: Association between a visit to the Yatra, changes in behavioral determinants and changes in food related handwashing with soap 12 Perceived severity Yatra visit Instrumental beliefs Descriptive norm Action self-efficacy Action control Changes in food related handwashing with 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. R 2 =.60 Direct effect n.s

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 13 Health knowledge Affective beliefs Perceived vulnerability Commitment Mediation model: significant indirect effects Changes in food related handwashing with soap Yatra visit

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 14 Health knowledge Affective beliefs Perceived vulnerability Commitment Mediation model: significant indirect effects Changes im essensbezogenen Händewaschen mit Seife Yatra visit BC 95% CI CoefficientSELLUL

Conclusions Evaluation of “The Great WASH Yatra” 15  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