How can you make people wash their hands? Gross them out

A new analysis of handwashing efforts in Indian villages found that leveraging emotional motivators, such as feelings of disgust or nurture, is more effective at promoting long-lasting behavior changes than traditional health messaging.

Diarrhea causes about 800,000 deaths annually among children under age five, says study author Val Curtis of the London School of Hygiene & Tropical Medicine. Handwashing with soap could prevent at least one-third of these deaths, yet surveys show that handwashing remains infrequent in countries that lack regular running water and suboptimal in countries that do not.

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"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," Curtis explains, adding, "Understanding the motivating factors for routine hand washing is essential to any initiative likely to achieve lasting behavior change."

Details of 'SuperMum' campaign

For the analysis, published in The Lancet Global Health, researchers from the United Kingdom and St. John's Research Institute, along with the Bangalore communications firm Centre of Gravity, tested whether the village-level "SuperMum" campaign could increase handwashing with soap in southern Andhra Pradesh, India. The intervention adapted an online, global toolkit that targets emotional drivers found to be successful for driving behavior changes, including:

• Nurture: The desire for a happy, thriving child;
• Disgust: The need to avoid and eliminate contamination;
• Affiliation: The yearning to fit in with what others in the community are believed to be doing; and
• Status: The drive to have greater access to resources than others.

The researchers randomly assigned 14 villages of between 700 and 2,000 people to receive the emotion-driven intervention or no intervention. For the villages who were selected to take part in the campaign, workers held community and school-based events involving comedic skits, animated films, and public pledging ceremonies that asked women to promise that they wash their hands at key times and ensure that their children do the same.

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At the start of the study, handwashing was low among both the intervention and control groups—between 1% and 2%. However, the study found that:

• After six weeks, handwashing compliance in the intervention group was 19%, compared with 4% in the control group;
• After six months, compliance in the intervention group had increased to 37%, compared with 6% in the control group; and
• After one year, when the control group had also received a shortened version of the campaign, handwashing in both groups was 29%.

According to study co-author Katie Greenland, the campaign is effective because "it engages people at a strong emotional level, not just an intellectual level."

However, Elli Leontsini and Peter Winch from the Johns Hopkins Bloomberg School of Public Health cautioned that the results were comparable to that of other studies. They wrote, "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" (Medical News Today, 2/27; Biran et al., The Lancet, March 2014).