How Behavioral Science Can Promote Hand-washing Behavior
With urban migration on the rise, cities are not only facing an increased influx of people, but they also have to find solutions to many of its consequences: lack of infrastructure, housing shortage and massive amounts of unclean water. For the urban poor, having access to drinking water cannot be equated with access to safe drinking water. On a yearly basis, around 300,000 children worldwide die because of water-borne illnesses.
Splash, a global nonprofit, is committed to creating safe water, sanitation, and hygiene (WASH) programs for school children across India, South East Asia and Africa by supplying handwashing stations and clean water fountains educating children on hygiene behaviors and driving policy and infrastructure changes in schools, orphanages and local governments.
In October 2017, Splash convened its first of two Behavior Change Summits. Together with other experts, Ting Jiang, Principal of CAH’s Global Health and Development team, and David Neal, Executive in Residence, provided ideas on behavior-based interventions that would maximize Splash’s impact.
Our team contributed to two main ideas to improve the rate of students washing their hands with soap after using the toilet. First developed by Robert Dreibelbis, the team built on the idea of painting colorful footsteps on bathroom floors that lead children from the toilet to the handwashing stations. Kids like to play, and colorful footsteps are a fun way to get them to walk to the handwashing stations. The footsteps also provide an immediate visual cue to remind kids to wash, thus helping to overcome the “intention behavior gap.”
Second, inspired by the Kenyan handwashing station Mrembro, CAH suggested the addition of mirrors above handwashing stations. Though they are not prevalent in many households, mirrors are an exciting object that attracts the attention of many children. Once drawn to the mirror by curiosity, they will remember to wash their hands. Repeating this behavior of going to the toilet and being drawn to the handwashing station by either footsteps or the mirror, will eventually instill a ritual of handwashing behavior in the children. This idea builds on the concept of a “Trojan horse” – that is, a product feature that is intrinsically rewarding (the mirror) and triggers people to interact with a product, where they are then more likely to perform the real, intended behavior (washing their hands).
Based on CAH’s contribution to the experimental design, both the footsteps and the mirror idea were field-tested in the months to follow the summit.
Nina Bartmann, Behavioral Researcher at CAH, and David Neal, Executive in Residence at CAH, attended the second Behavior Change Summit in July 2018, at which Splash presented preliminary results from Addis Ababa, Ethiopia. According to this pilot, the mirror intervention increased the percentage of students who washed both hands with water and soap after using the toilet from 25% to 62%, where as the footsteps only increase handwashing behavior from 27% to 29%. However, certain logistical challenges may have limited the impact of the painted footsteps (finding local paint products that could sustain heavy foot-traffic in the school environment).
Lastly, over the course of both Behavior Change Summits, CAH also contributed to Splash’s overall Behavior Change Strategy. In particular, we focused on how to address the intention-behavior gap and how to incorporate habit change into their model. The intention-behavior gap is a common phenomenon where one has an intention to act (e.g., to wash their hands regularly) but tends to forget or be disrupted in following through on that intention.
The results presented at the second Behavior Change Summit speak for itself: Splash is not only successfully delivering hardware that allows for handwashing, but is also able to influence children’s behavior by incorporating behavioral science principles. We are confident that through the use of evidence-based interventions we can effectively change behavior that would further prevent death caused by water-borne illnesses.