Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2015 Behaviour, cognitions, and the environment : the influence of contextual factors and social-cognitive determinants on handwashing practices in infrastructure-restricted settings Seimetz, Elisabeth Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-124511 Dissertation Published Version Originally published at: Seimetz, Elisabeth. Behaviour, cognitions, and the environment : the influence of contextual factors and social-cognitive determinants on handwashing practices in infrastructure-restricted settings. 2015, University of Zurich, Faculty of Arts. Behaviour, Cognitions, and the Environment: The Influence of Contextual Factors and Social-Cognitive Determinants on Handwashing Practices in Infrastructure-Restricted Settings Thesis (cumulative thesis) Presented to the Faculty of Arts and Social Sciences of the University of Zurich for the Degree of Doctor of Philosophy by Elisabeth Seimetz Accepted in the Autumn Term 2015 on the Recommendation of the Doctoral Committee: Prof. Dr. Hans-Joachim Mosler and Prof. Dr. Urte Scholz Zurich, 2015 Abstract Even though morbidity and mortality due to diarrhoeal diseases in children less than five years old have declined more than 50% over the past 15 years, diarrheal infections still remain among the leading causes of childhood death in developing countries. Washing hands with soap at critical junctures, such as after defecating and before eating or preparing food, has been shown to be effective in reducing the occurrence of diarrhoea. Still, rates of handwashing with soap in developing countries remain remarkably poor. To effectively promote a desired behaviour, it is first of all important to understand what influences and determines that behaviour. Many health promotion programmes are based on social-cognitive theories that have been developed to understand and predict health behaviour. Although the role of the environment in influencing health behaviour is increasingly being recognized, most interventions still remain by and large focused on individual factors. Research taking into account physical and social environmental influences along with social-cognitive aspects of behaviour and their interactions is limited. The present thesis aims to contribute to the prediction and understanding of handwashing behaviour in infrastructure-restricted settings by focusing on how social-cognitive determinants in combination with the physical and social environment influence handwashing practices across different populations and settings. A theoretical framework is proposed in this thesis that acknowledges the interconnectedness and interdependence of contextual and social-cognitive determinants of behaviour. The framework divides context into the social environment, the physical environment, and characteristics of the individual. The operationalization of the social-cognitive factors was based on the RANAS (risk, attitudes, norms, abilities, self-regulation) model, which integrates key constructs from major social-cognitive models. The first study was conducted to assess the effect of a large-scale handwashing awareness raising campaign in rural India on changing the participants’ intention to wash hands with soap and the underlying social-cognitive determinants. Interviews were conducted with 687 visitors before and after their visit to the event. While only a marginal increase in the visitors’ intention to wash hands was found, the results suggest that this unique social, cultural, and informational environment was successful in changing visitors’ knowledge of the causes of diarrhoea, beliefs about the benefits of washing hands, feelings of liking and disgust about the behaviour, and injunctive normative beliefs. Still, the marginal increases in the visitors’ intentions to wash hands proved that substantively changing behaviour might require more than improving knowledge and emphasizing the importance of washing hands. II The second study was conducted in northern rural Burundi as part of a baseline study for the next project phase and explored the role of environmental factors along with social-cognitive determinants in predicting handwashing practices at household level among caregivers of primary school children (N = 660). Hierarchical regression analyses showed that household wealth, the amount of water available per person in the household, and having a designated location for washing hands were contextual factors that significantly predicted handwashing frequency, whereas the time spent collecting water and the amount of money spent on soap per person per month were not. Adding the RANAS social-cognitive factors to the model substantially improved the prediction of handwashing frequency, while at the same time, the predictive effects of household wealth and having a designated location for handwashing disappeared. The final model indicates that high handwashing frequency is most likely among caregivers who are certain that they can always execute the behaviour before handling food and after contact with stool, who plan when, where, and how to wash hands, and who report not forgetting to wash hands at those critical junctures. The full and partial mediation effects of contextual factors through social-cognitive factors are examples of the potential impact of interactions between these factors on handwashing frequency. The findings suggest that contextual constraints might be perceived rather than actual barriers and highlight the value of psychosocial factors in understanding hygiene behaviours. In the last study, a survey assessing the RANAS social-cognitive determinants was used to identify the relevant factors underlying primary school children’s handwashing practices in rural Burundi and urban Zimbabwe. Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. While taking into account observational findings on school handwashing characteristics, analyses revealed that information interventions to raise the children’s perception of the severity of contracting diarrhoea in Burundi and to enhance knowledge of how to contract and prevent the disease among school children in Zimbabwe should be implemented. Infrastructural interventions were proposed for both countries to enhance the children’s confidence in their ability to wash hands after using the latrine. Lastly, an intervention was planned at every school highlighting the commonness of handwashing to tackle social norms. The goal of the intervention strategies is to create an enabling social-relational, informational, and infrastructural environment for handwashing practices at school. The findings of this thesis indicate that considerably more attention should be given to the role of contextual factors and their interaction with social-cognitive factors when examining III the determinants of handwashing behaviour in infrastructure-restricted settings. In light of the framework proposed here, the results suggest that risk perceptions, attitudes, and social norms are mostly influenced by the social environment, whereas abilities and self-regulation factors are mainly affected by the physical environment. Even though future research is still required to elucidate the role of these factors in producing behavioural change, it is to be hoped that researchers and practitioners will consider environmental aspects and their dynamic interplay with social-cognitive determinants to a far greater extent when designing handwashing programmes. IV Zusammenfassung Obwohl Morbidität und Mortalität aufgrund von Durchfallerkrankungen bei Kindern unter fünf Jahren in den letzten 15 Jahren um mehr als 50% zurückgegangen sind, zählen Durchfallerkrankungen nach wie vor zu den häufigsten Todesursachen bei Kindern in Entwicklungsländern. Händewaschen mit Seife in kritischen Momenten, wie z.B. nach dem Stuhlgang, vor dem Essen oder vor der Zubereitung von Lebensmitteln, hat sich als wirksam erwiesen, um die Prävalenz von Durchfall zu verringern. Dennoch ist die Häufigkeit von Händewaschen mit Seife in Entwicklungsländern bemerkenswert niedrig. Um ein gewünschtes Verhalten wirksam zu fördern, ist es zunächst wichtig zu verstehen, wodurch das Verhalten beeinflusst und bestimmt wird. Viele Programme zur Gesundheitsförderung basieren auf sozial-kognitiven Theorien, die entwickelt wurden, um Gesundheitsverhalten zu verstehen und vorherzusagen. Obwohl die Rolle des Kontextes bei der Beeinflussung von Gesundheitsverhalten zunehmend anerkannt wird, basieren die meisten Massnahmen immer noch weitgehend auf individuellen Faktoren. Untersuchungen die sowohl physische und soziale Umwelteinflüsse, als auch sozial-kognitive Aspekte des Verhaltens und deren Interaktionen berücksichtigen, sind begrenzt. Ziel der vorliegenden Arbeit ist die Vorhersage und das Verständnis von Händewaschverhalten im Kontext begrenzter Infrastruktur mit Fokus auf dem Einfluss sozial-kognitiver Faktoren in Kombination mit der physischen und sozialen Umwelt in verschiedenen Populationen und Kontexten. In dieser Arbeit wird ein theoretisches Modell vorgestellt, das die Vernetzung und gegenseitige Abhängigkeit von kontextuellen und sozial-kognitiven Determinanten des Verhaltens hervorhebt. Das Modell unterteilt Kontext in soziales Umfeld, physische Umwelt und individuelle Eigenschaften. Die Operationalisierung der sozial-kognitiven