Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe

BMC Research Notes, Jul 2017

Background This article presents the development of a school handwashing programme in two different sub-Saharan countries that applies the RANAS (risk, attitudes, norms, ability, and self-regulation) systematic approach to behaviour change. Methods Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. Regression analyses were used to assess the influence of the RANAS behavioural determinants on reported handwashing frequencies. Results The results revealed that, in both countries, a programme targeting social norms and self-efficacy would be most effective. In Burundi, raising the children’s perceived severity of the consequences of contracting diarrhoea, and in Zimbabwe, increasing the children’s health knowledge should be part of the programme. Conclusions The school handwashing programme should create awareness of the benefits of handwashing through educational activities, raise the children’s ability and confidence in washing hands at school through infrastructural improvements, and highlight the normality of washing hands at school through events and poster creation.

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Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe

Seimetz et al. BMC Res Notes Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe Elisabeth Seimetz 0 Jurgita Slekiene 0 Max N. D. Friedrich 0 HansJ‑oachim Mosler hans‑ 0 0 Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science & Technology , Ueberlandstrasse 133, P.O. Box 61, 8600 Duebendorf , Switzerland Background: This article presents the development of a school handwashing programme in two different subSaharan countries that applies the RANAS (risk, attitudes, norms, ability, and self‑ regulation) systematic approach to behaviour change. Methods: Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. Regression analyses were used to assess the influence of the RANAS behavioural determinants on reported handwashing frequencies. Results: The results revealed that, in both countries, a programme targeting social norms and self‑ efficacy would be most effective. In Burundi, raising the children's perceived severity of the consequences of contracting diarrhoea, and in Zimbabwe, increasing the children's health knowledge should be part of the programme. Conclusions: The school handwashing programme should create awareness of the benefits of handwashing through educational activities, raise the children's ability and confidence in washing hands at school through infrastructural improvements, and highlight the normality of washing hands at school through events and poster creation. Handwashing with soap; Diarrheal; Behavioural determinants; Campaign development; School children; Sub‑ Saharan Africa Background Handwashing promotion programmes are increasingly being implemented in developing countries to improve child health and development. Since schools are important settings for disease transmission, school-based interventions aiming at mitigating communicable diseases are likely to reduce the overall community disease burden [ 1, 2 ]. According to the WHO/Unicef Integrated Global Action Plan for Pneumonia and Diarrhoea [3], improving access to safe drinking water, providing adequate sanitation, and promoting good hygiene behaviour, such as handwashing with soap, are essential for preventing diarrhoea. In primary schools, interventions promoting handwashing with soap have proven to be effective in reducing infectious diseases in pupils [ 4–6 ], Potential constraints include lack of soap and water and the absence of adequate handwashing facilities [ 7–10 ]. Increasing the provision of soap and water for handwashing has caused decreases in absenteeism [ 6, 11, 12 ], and several studies have reported an association between proper handwashing behaviour and the availability and accessibility of handwashing facilities [ 13–15 ]. For handwashing behaviour to be adopted and become a habit, it is not enough to provide proper resources and facilities. Growing evidence suggests that health behaviours such as dietary habits, physical activity patterns, and substance abuse are predicted by such social-cognitive factors as attitude, subjective norms, and self-efficacy beliefs [ 16–18 ]. Several studies have indicated that hand hygiene practices depend largely on psychological factors within the individual [ 19–21 ]. So far, very few studies have investigated behavioural determinants underlying children’s handwashing practices. Two studies have drawn on the theory of planned behaviour to examine factors affecting proper handwashing. Research by Lopez-Quintero, Freeman, and Neumark [ 21 ] in Colombia showed that intentions to perform proper handwashing were determined by perceived control, personal attitudes, and subjective norms. Setyautami, Sermsri, and Chompiku [ 13 ] found that students with positive attitudes and perceived behavioural control were twice as likely to wash their hands properly. Several studies have used the knowledge, attitudes, and practices approach to examine the influence of school children’s knowledge, attitudes, and practices on hygiene behaviour; they have reported mixed results concerning the importance of knowledge in determining proper handwashing behaviour [ 14, 22–24 ]. Although attitude was mentioned as an important indicator for hygiene behaviour in all of these studies, it was not assessed above and beyond knowledge and practice. More importantly, selfregulatory processes such as action control and feelings of self-efficacy have not yet been investigated. Researchers urge the use of theories of behaviour change for developing interventions and programmes to change health behaviour [ 25, 26 ]. Promoting proper handwashing practices is challenging, and the effectiveness of handwashing interventions have been inconsistent [27]. Applying behaviour change theories to promotion programmes for handwashing may increase their potential for changing (...truncated)


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Elisabeth Seimetz, Jurgita Slekiene, Max N. D. Friedrich, Hans-Joachim Mosler. Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe, BMC Research Notes, 2017, pp. 280, Volume 10, Issue 1, DOI: 10.1186/s13104-017-2599-4