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)