Using behavioural science to encourage handwashing in India

By Gayatri Koshy, Head of mHealth

Is it possible to encourage people to wash their hands without even mentioning the word ‘germs’? Yes. A handwashing intervention inspired by behavioural science in rural India was a big success precisely because it did not talk about germs. Instead, it reached out to deeper motivating factors behind human behaviour, engaging people on an emotional level.

Preventable deaths

Diarrhoea is a leading killer of children, accounting for approximately 8 per cent of all deaths among under fives worldwide in 2017 It’s estimated that handwashing with soap could prevent one third of these deaths (Ejemot-Nwadiaro et al. 2015).

Handwashing campaigns typically try to inform and educate people with messages about germs and diseases and the health benefits of handwashing. But they’ve had little success. Studies in India, Ghana, China, Bangladesh and Kenya show that only 2-29 per cent of people wash their hands with soap after toilet use (Biran et al. 2009; Scott et al. 2007; Curtis et al. 2009; Aunger et al. 2010). Even in the UK, where soap and water are conveniently available and education levels are high, handwashing levels are less than optimal (Curtis et al. 2003; Judah et al. 2009). All this suggests that achieving effective and lasting behaviour change needs more than just communication of information and easy access to soap and water.

Emotional motivators

In 2011, the handwashing intervention was rolled out in rural India. It targeted mums and aimed to promote handwashing with soap before eating and after using the toilet. This behaviour change intervention was unique because instead of educating mums about the health benefits of handwashing, it appealed to three emotional motivators to encourage handwashing:

  1. Nurture, the desire for a happy and healthy child.
  2. Disgust, the desire to avoid and remove contamination.
  3. Social norms, the desire to conform with the rest of society.

The campaign focused on a central character ‘SuperAmma’ (SuperMum), a likeable, forward-thinking mother who had a loving, nurturing relationship with her son, teaching him good manners, such as handwashing with soap before eating and after using the toilet. The campaign also featured a comical male character who was prone to disgusting habits that contrasted to those of SuperAmma. Skits, posters, flipcharts and presentations at community meetings were used to reach the audience.

Sustainable behaviour change

An evaluation of the SuperAmma behaviour change intervention showed great results. Six months after the campaign was rolled out in 14 villages in Andhra Pradesh, rates of handwashing with soap had increased by 31 per cent, compared to communities without the programme, and were sustained for 12 months. The intervention succeeded by developing an understanding of the drivers of handwashing behaviour and a design process that allowed full use of these insights. The mode of delivery was inspired by commercial practices used to deliver branded campaigns to millions of consumers across India.

A behaviour change campaign must understand its audience and get a sense of what drives them, what motivates them. Reaching the audience intellectually by educating and informing can only go some way towards behaviour change. The SuperAmma campaign has shown us that in order to achieve long-lasting behaviour change, it’s just as important to appeal to the audience at a deeper more emotional level as well.

Gayatri is the Head of mHealth at Thrive. With a Master of Public Health (MPH) degree, she has extensive experience working in global health projects as well as national level programmes such as India’s National AIDS Control Programme.

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