Hygiene (Handwashing) Behaviors Mark D. Sobsey ENVR Spring, 2009

Effect of Handwashing on Diarrhea Risk - Curtis and Cairncross (2003)

Positive Associationd of HW with Other WASH Factors

Hygiene Behavior Studies - Curtis Et. al, 2009 Planned, motivated and habitual hygiene behaviour: an eleven country review Health Educ Res Mar 13. [Epub ahead of print] Results of a series of formative research (FR) studies Used the perspectives and methods of medical and biological anthropology, as well as of consumer science Helped elucidate a range of factors associated with risky hygiene behavior Aimed to provide insights needed to develop strategies for changing handwashing behavior

Conceptual Model of the Causes of Behavior

Environment Environmental factors influencing behavior were divided into 3 components: ‘social’ –The individuals, groups and institutions (e.g. local norms, national regulations and religion) that influence the behavior of the target individual ‘physical’ –The geographic, climatic, material and artefactual factors affecting behaviour (e.g. water and sanitation availability and house design) ‘biological’ –Other life forms and their products (e.g. foodstuffs, domestic animals and disease agents) that influence behavior Assumed that salient changes in the environment lead to changes in the brain which can lead to changes in behavior

Environmental factors influencing HWWS

Behavior - Brain Assigned behavior to 3 types of discrete but interacting causes –Cognitive or executive control which produces ‘planned’ behavior, –the reward system which produces ‘motivated’ behavior –Automatic or reflexive control which is responsible for ‘habitual’ behavior Based on recent thinking in social and evolutionary psychology and neuroscience

Habit Learnt automated behaviors produced by cues, often as part of a routine The most primitive psychological system involved in handwashing behavior is ‘habit Learnt, automated behavior that can be regularly triggered by a particular cue Mothers often ascribed handwashing (HW) habits to what they were taught when they were young The habit of washing with plain water was much more frequent than HWWS –It sometimes occurred as a part of religious ritual, a special form of habit

Motivation Tendency to do work to put oneself into a state that was good for the survival and reproduction of our ancestors (includes drives and emotions) Motivations concerning HWWS Disgust – Tendency to avoid objects & situations carrying disease risk Status – Tendency to seek to optimize social rank Affiliation – Tendency to seek to conform so as to reap the benefits of social living Attraction – Tendency to be attracted to, & want to attract, high-value mates Nurture – Tendency to want to care for offspring Comfort – Tendency to place one’s body in optimal physical, chemical conditions Fear – Tendency to avoid objects & situations carrying risk of injury or death

Motivation - Results ‘Disgust’ emerged as a motivator of HW in all the studies Hands had to be washed when they became contaminated with organic material that was dirty, foul or smelly. Most commonly mentioned contaminants: –Feces, fish, urine, bodily fluids, rotten or dead items Feces were found to be particularly repulsive. –Some, the smell or sight of feces alone was enough to motivate HW –Others: hands that had not obviously contacted fecal material during toileting did not need washing.

Planning The pursuit of long-term objectives Looked for ways in which caretakers constructed plans to use HW to help achieve some form of long-term end or objective. Planned behavior is distinct from –motivated behavior, which aims at short-term reward, or –habitual behavior which is automatic and cue-based 1. HW could help to provide a platform of good health for all the family. 2. HW was sometimes carried out for the sake of beneficial supernatural objectives, e.g., being in a state of religious purity or of having ‘good luck’. 3. Caretakers made plans to teach children HW to socialize them correctly There was a chain of logically connected representations which linked HW to some form of long-term beneficial objective. But for some, HW gets in the way of achieving long-term plans Health as a long-term objective is often described as being instrumental in meeting other objectives, such as being beautiful, or saving money.

Belief/knowledge that linked HW to long-term beneficial outcomes Flaws we found flaws in the chain of belief/knowledge that linked HW to long- term beneficial outcomes. Knowledge of germ theory of disease was widespread, but.. Germs remained essentially abstract; they are invisible and undetectable. Mothers have learnt that poor hygiene causes ‘diarrhea’ in children Yet mothers often did not recognize this condition as a disease Diarrhea is just a symptom, either of normal child development (e.g. teething) or of another underlying disease. Diarrhea was not seen as life-threatening or as relevant to one’s own children It was thought to be mild and self-limiting, hence unlikely to lead to other adverse outcomes. Thus, the chain of associations that would make it worthwhile to go to the trouble of washing hands with soap is probably too tenuous to cause mothers to make conscious plans to always carry it out –Benefits associated with preventing child diarrhea, and hence the possible serious illness or loss of the child, are to distant and uncertain

Key Findings Only a mean 17% of child caretakers HWWS after toileting Handwash ‘habits’ were generally not inculcated at an early age Key ‘motivations’ for HW: –Disgust –Nurture –Comfort –Affiliation Fear of disease generally did not motivate HW –except transiently in cholera epidemics ‘Plans’ involving HW: –improve family health –teach children good manners. Few environmental barriers –soap and water was available in almost every household

Key Findings HW is habitual, so self-reporting of factors determining it is unreliable Candidate strategies for promoting HWWS: –creating social norms, –Highlighting disgust of dirty hands –teaching children HWWS as good manners. Providing a simple, but comprehensive conceptual model: –Divide the factors determining health-related behavior into planned, motivated and habitual categories Habitual aspects of many health-relevant behaviors require further study

Summary HWWS at key junctures, such as following the toilet, is rare. Handwashing practices are often automated and habitual, and established during childhood. Since HWWS is rare, the perception of this social norm encourages people ‘not’ to do it. Hence, one of the tasks of handwashing communication should be to make HWWS ‘seem’ common (billboards, advertisements, seen in TV dramas, etc). While fear of epidemics such as cholera can motivate handwashing, the motivation does not outlast the epidemic. Disgust can be a potent motivator of HWWS. Messages about the disgusting nature of the material that gets on hands in the toilet can encourage handwashing and be highly memorable.

Summary While mothers may not make specific long-term plans to avoid disease, they do plan to teach the social arts to their children. Persuading mothers that a child that washes hands with soap is demonstrating good manners may be an effective means of getting habits established early. The study highlights the importance of continuing to develop the theory and practice of health promotion so as to be able to encompass concepts such as motivation, emotion and habit, in the light of emerging developments in psychology, anthropology and marketing.