Elisabeth Seimetz Hans-Joachim Mosler

1. Evaluation of a handwashing awareness raising campaign in IndiaThe effect of “The Great WASH Yatra”on handwashing with soap Elisabeth Seimetz Hans-Joachim Mosler

2. Handwashing with soap Crucial behavior to the reduction of diarrheal diseases • Each year, 760.000 children under the age of five die due to diarrheal diseases (WHO, 2013) • Diarrhea is the second leading cause of death among children under five in developing countries (Bryce, Boschi-Pinto, Shibuya, & Black, 2005; Walker et al., 2013) • Handwashing with soap at key moments can cut diarrhea risk by almost half (Cairncross et al., 2010; Curtis & Cairncross, 2003 ) • Handwashing with soap is a rather simple and cost-effective task with a high protective effect (Curtis et al., 2000; Curtis et al., 2011) • Despite its protective effect, handwashing with soap is practiced at surprisingly low rates (Scott, Curtis, & Rabie, 2003)

3. The Great WASH Yatra Nirmal Bharat Yatra • Multi-channel mega-awareness traveling campaign • Playful promotion of life-saving handwashing behavior • Focus on the positive power of Cricket and Bollywood

4. The Great WASH Yatra Nirmal Bharat Yatra • Developed by: • Primary funding: Swiss Agency for Development and Cooperation (SDC) • 2’000 km • 5 Indian states • 6 location • From 2 October until 19 November 2012 Wardha, Maharashtra Indore, Madhya Pradesh Kota, Rajasthan Gwalior, Madhya Pradesh Gorakhpur, Uttar Pradesh Bettiah, Bihar

5. The Great WASH Yatra Games andactivities

6. Theoretical Background of the Evaluation Study RANAS model of behavior change (Mosler, 2012) • Integration of various elements from theories of behavior change: • Health belief model Rosenstock, 1974 • Theory of Planned Behaviour Ajzen, 1991 • Health Action Process Approach Schwarzer, 2008

7. RANAS model of behavior change (Mosler, 2012) Identification of the Behavioral Determinants Classification of the behavioral determinants into five factor blocks: RiskPerceived vulnerability – Perceived Severity – Factual knowledge Attitude Instrumental beliefs – Affective beliefs Norm Descriptive norm – Injunctive norm Ability Action knowledge – Action self-efficacy – Maintenance self-efficacy Self-regulation Action Planning – Coping Planning – Remembering – Commitment

8. Evaluation of “The Great WASH Yatra” Assessing the effect of the intervention Intervention Behavioral determinants Behavior Risk Attitude Handwashing with soap and water Norm Yatra visit Ability Self-regulation

9. Evaluation of “The Great WASH Yatra” Household surveys before and after the campaign • Target group: primary caregivers within a household with a child below 5 years • Structured face to face interviews of 30-40 minutes • Structured observations of three hours • The same caregivers were surveyed before and after the campaign • Baseline survey • Follow-up survey Interviews: N = 1145 Observations: N = 186 Interviews: N = 990 (86%)  139 Yatra visitors Observations: N = 139 (75%)  17 Yatra visitors

10. Evaluation of “The Great WASH Yatra” Handwashing rates before and after the campaign • Self-reported handwashing • Stool related • After using the toilet • After wiping a child’s bottom • After other kinds of contact with stools • No significant increase in the visitors and in the non-visitors group

11. Evaluation of “The Great WASH Yatra” Handwashing rates before and after the campaign • Self-reported handwashing • Food related • Before cooking • Before eating • Before handling drinking water • Before feeding a child • Significant increases in the visitors and in the non-visitors group (p < .001) • Significant difference between the increases in the visitors and the non-visitors group (p = .021)

12. “The Great WASH Yatra”: Mediating Effects Mediation model: Association between a visit to the Yatra, changes in behavioral determinants and changes in food related handwashing with soap Changes in risk perceptions Perceived vulnerability Perceived severity 0.43 0.06 Health knowledge Changes in attitudes Instrumental beliefs 0.53 0.27 Affective beliefs Changes in food related handwashing with soap 0.16 0.14 Changes in norms Yatra visit Descriptive norm 0.20 Injunctive norm Changes in abilities Adj. R2 = .60 Action self-efficacy Maintenance self-efficacy 0.34 0.45 Changes in self-regulation Action control Remembering Commitment Direct effect n.s. Path values are standardized regression coefficients. The original scales range from 1 to 5. Only significant coefficients with p < .05 are displayed. N = 990.

13. “The Great WASH Yatra”: Mediating Effects Mediation model: significant indirect effects Changes in risk perceptions Perceived vulnerability Perceived severity Health knowledge Changes in attitudes Instrumental beliefs Affective beliefs Changes in food related handwashing with soap Changes in norms Yatra visit Descriptive norm Injunctive norm Changes in abilities Action self-efficacy Maintenance self-efficacy Changes in self-regulation Action control Remembering Commitment

14. “The Great WASH Yatra”: Mediating Effects Mediation model: significant indirect effects Changes in risk perceptions Perceived vulnerability Perceived severity Health knowledge Changes in attitudes Instrumental beliefs Affective beliefs Changes im essensbezogenen Händewaschen mit Seife Changes in norms Yatra visit Descriptive norm Injunctive norm Changes in abilities Action self-efficacy Maintenance self-efficacy Changes in self-regulation Action control Remembering Commitment

15. Evaluation of “The Great WASH Yatra” Conclusions • Stool related handwashing behavior • Food related handwashing behavior • No increase in either group • Higher increase in the visitors group • Higher increase can be explained through a higher increase in several behavioral determinants: • Perceived vulnerability • Health knowledge • Affective beliefs • Commitment