Involving Children For Hand Washing Behavior Change: Repeated Message Delivery to Foster Action

Table of Contents

CHAPTER ONE: INTRODUCTION
1.1 Background to the Study
1.2 Statement of the Problem
1.3 Objectives of the Study
1.4 Significance of the Study
1.5 Delimitation and Limitations
1.6 Definition of Terms

CHAPTER TWO: REVIEW OF RELATED LITRATURE
2.1 Hand Washing as Hygiene Tool
2.1.1 Magnitude of Diarrhea and Hygiene Related Risks
2.1.2 Behavior Risk factors
2.1.3 Critical Time for Hand Washing
2.1.4 Hand washing Practice
2.1.5 Impact of Hand Washing
2.2. Theoretical Frameworks
2.2.1. Theory of Reasoned Action (TRA)
2.2.2 Theory of Planned Behavior (TPB)
2.2.3. Integrative Behavioral Prediction (IBP)
2.2.4 Communication for Behavior Change
2.2.4.1 Communication Strategies
2.2.4.2 Communication and Attitudinal Change
2.2.4.3 Health Communication Principles
2.2.5 Complementary Relationship for maximum result
2.3 Intervention by Communication
2.3.1 Appropriateness of the Intervention
2.3.2 Intervention using Multimedia: Community level
2.3.3 Intervention using Multimedia: School level

CHAPTER THREE: METHODOLOGY
3.1. Research Design
3.2. Study area
3.3. Participants of the Study
3.4. Sampling procedures and sample size
3.5. Variables
3.6. Instrumentation and Measures
3.7. Data Collection
3.8. Identification of Beliefs for Intervention
3.9. Experimental manipulations or interventions
3.10. Effectiveness of the Intervention
3.11. Validity and Reliability
3.12. Ethical consideration
3.13. Data Analysis Method

CHAPTER FOUR: RESULTS AND DISCUSSION
4.1 Results of the Descriptive Data

CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMENDATION
5.1. Summary
5.2. Conclusion
5.3. Recommendations

APPENDICS

Appendix 1: Informed Consent (Modified from Maddison R, 2000)
Appendix 2 : Questionner
Appendix 3: Amharic Translations of all data collection instruments
Appendix 4: Hand washing interpretation and score making Larson & Lusk, (1985) second model
Appendix 5: On spot house observation check list used for this research adapted from Stephen P. Luby, (2009)
Appendix 6: Elicitation questions adopted from Glanze K.(2005)
Appendix 7:- The verse of the hand washing song that developed by the researcher and utilized for communication of hand washing message.
Appendix 8: Picture of How to wash hand with soap and critical moments (USAID)

ACKNOWLEDGEMENTS

The researcher would like to thank Reda Darge (Asso. Prof.) for his valuable assistance and guidance with this research. Additional thanks to Chandba Full Cycle Primary School Principal Ato Beka Kebta for his support and contribution to select students and willingness in allowing the researcher to implement all intervention component in this work. The researcher also wishes to thank Ato Tegaye Habte for his great support in giving transport service. I wish to thank all students which participated in the experiment, data collectors, Chandba Primary School, Gondar Education Media Center staff and Amhara Region Education Bureau.

Finally, I wish to thank Anteneh, my brother, for his continued support and encouragement throughout my work.

LIST OF TABLES

Table 1:Media Priming Intervention Matrix

Table 2: Pearson product moment correlation coefficient between IBP variables and their corresponding underlining beliefs

Table 3: The coefficient of Determination of each underlining belief to their respective IBP variables in pre and post intervention

Table 4: Correlation between six IBP variables to intention pre and post intervention

Table 5: Summary of ANOVA for prediction of pre-intervention Intention

Table 6: Regression analysis for prediction of per intervention Intention

Table 7: Multiple regression analysis for prediction of Intention

Table 8: Results of Wilcoxon’s Match-Pairs Sign Rank test of Knowledge change

Table 9: Results of Wilcoxon’s Match-Pairs Sign Rank test of Hand washing skill change

Table 10: Direct effects of Variables on Behavior

Table 11: Change percentage of participant’s number before and after intervention who are with positive trend

Table 12: The communication effects of the six behavioral beliefs

Table 13: Descriptive Statistics of pre and post intervention intention and behavior

Table 14: Frequency of the Complementarity variables

Table 15: Summary of ANOVA table for Complementarity test

Table 16: Media Exposure direct effects on Beliefs, Intention, and Behavior change

LIST OF FIGURES

Figures

Figure 1: The F-Diagram

Figure 2: Integrated Behavior Model

Figure 3: Conceptual Framework

Figure 4: Summary of Descriptive Statistics Pre and Post intervention

LIST OF ABBREVATIONS/ ACRONYMS

illustration not visible in this excerpt

ABSTRACT

This experimental study investigated the presence of complementarity between Integrative Behavior Prediction(IBP) to identify beliefs to change and media priming effect to increase the association between positive intention and behavior of hand washing with water and soap at the three critical moments(i.e., before eating , before touching or preparing food, and after defecation). Using purposive sampling 34 participants was selected. The participants are grade six students of Chandba Primary School in Chilga woreda North Gondar Zone Amhara Region in Ethiopia. The research method is mixed where both quantitative and qualitative methods are employed for data collection and analysis. Before the one month intervention time elicitation information collected through interview used to develop the questionnaire administered before and after intervention. In addition to this on spot house observation and hand washing skill evaluation tool were utilized to collect data. The intervention treatment has been done through multimedia communication and practical participation of students in all the activities. The result indicates significant correlation between normative belief-others behavior and descriptive norm both in pre and post intervention time (r = 0.465, p< .01, and r = 0.460, p< .01 respectively). In addition to these significant correlations were observed between pre intervention normative belief-others expectation and Injunctive norm (r =0 .486, p< .01). Injunctive norm is the strongest predictor of intention (F obtained 8.871, p< .000).Qualitative results indicated that multi-media communication, provision of small money to buy soap and empty plastic bottle to establish simple hand washing station (Tip tap) improved participants’ and their neighbors hand washing behavior positively. The result of post intervention exposure to message showed significant correlation with behavior (r = 0.720, p<. 01). Intention after intervention strongly correlated with behavior (r =0.712, p< .01). Regarding change Knowledge Zob=4.94 and practical skill Zob=5.08,p<.025 due to intervention. Finally significant positive compementarity relationship observed between IBP model and Priming effect theory (F =df1= 7,df2=26 5.579, p<.001). In conclusion, intention to promote important referents to wash their hand with soap and their encouragement, promotion to change student’s affective belief and strengthening their control belief, provision of hand washing facilities i.e., soap and empty plastic bottle for tip tap preparation contribute to change hand washing behavior. In addition to these, exposure to multimedia message and practical involvement of students improved their behavior resulted complementary synergy effect of IBP and priming theory. From the findings it was recommended that School administrators, teachers, media organizations, non-governmental organizations, health extension workers, and government health organizations should use research based participatory multi-media approach to get effective hygiene behavior change on primary school students.

CHAPTER ONE: INTRODUCTION

1.1 Background to the Study

Diarrhea and Pneumonia, according to UNICEF’s 2008 research, together account for almost 3.5 million child deaths annually worldwide. However, it was researched and documented that hand washing with soap is the single most effective and inexpensive way to prevent diarrhea and acute respiratory infections, as automatic behavior performed in homes, schools and communities (Hand washing Day-Wikipedia,2010). Human feces are the main source of diarrheal pathogens. They are also the source of Shigellosis, Typhoid, Cholera, and all other common endemic gastroenteric infections: just one gram of human feces can contain 10 million viruses and one million bacteria. These pathogens are passed through various routes from infected host to the new one, but they all emanate from one source: feces, where primary measures, the far more important primary barriers-sanitation and hand washing- after fecal contact has a great impact (Curtis, Cardosi, and Scott, 2000). Many official documents mentioned, change and stick to hand washing with soap before eating and after using the toilet into customary habit was projected to save more lives than any single vaccine or medical intervention, decreasing deaths from acute respiratory infections by one-quarter(Hand washing Day-Wikipedia;November, 2010). In Africa, diarrhea kills 1.5 million children every year (Greentudg, 2010), which is 18% of the cause of death (WHO 2010). The cause of under 5 deaths in Ethiopia 23% due to diarrhea, where under five mortality rates is 109 per 1000 lives birth (WHO Health Statistics, 2010).

Hand washing is an often over looked behavior that is very important for food safety, disease prevention, and personal health yet most people under estimate the potential seriousness of food borne illness and its correlation with hand washing practices (Hyde, 2010). Since diarrhea is principally spread by the foeco-oral route, wide spread adoption of simple proper hand washing practices during critical times could significantly reduce burden of the disease and save thousands of lives annually (Wossen, 2010).

Several research studies support the need for behavior change and the need of effective hand washing education. A research made in Hawaii indicated hand washing is important in the prevention of food borne illness caused due to transmission of pathogenic bacteria and viruses that include E.Coli O 157, Campylobacter, Salmonella, Shigella, and Hepatitis A. In a food borne diseases analysis (1994-1998), the Hawaii Department of Health reported 3,590 cases of Campylobacteriasiss, 507 cases of shigellosis, and 547 cases of Hepatitis A. In the same document a research done by Center for Disease Control (CDC) estimated that there are 78 million cases of food borne illness with 325,000 hospitalizations and 500 deaths each year. The CDC links poor sanitation to 34% of the documented cases of food borne illness (Susie, 2001).

Many studies reported an association between improvements in hand hygiene and reduction in rate of infectious illness in the community. For example, a meta analysis of 30 hand hygiene trials published from January 1960 through May 2007 indicated improvements in hand hygiene resulted, without education, reductions in gastrointestinal illness of 31% and reductions in respiratory illness of 21%. Where the most beneficial intervention was hand-hygiene education with use of common soap. Soap with education reduced gastrointestinal illness by 39% and respiratory illness by 51 % (Allison, Rebecca, Vanessa, & Elaine, 2008).

However, hand hygiene behavior in many communities is ignored, neglected or considered as wrong doing. According to WHO, 80% of infectious diseases in developing countries are related to inadequacies in education about sanitation and hygiene (Van Christine & Tineke, 1993). In different communities distinct beliefs prevent peoples from washing their hands properly at critical moments. Since each segment of the community adults, women, men, and children have different beliefs regarding hand washing behavior, they should be addressed differently. The issue of changing hand washing behavior of the community is a challenge of different disciplines including psychologists and media practitioners.

It is not surprising then that understanding the underlining motives for adopting and maintaining hand washing with soap at critical times has received a great deal of research attention on various places using different models targeting groups of a community.

New paradigms for understanding, studying, and applying knowledge about human behavior continue to arise and may be influential in the future of applied social sciences in health behavior and education. Many public health and behavior science educators strongly recommended, that “interventions on social and behavioral factors should link multiple levels of influence rather than focusing on a single or limited number of health determinants” (Karen, Barbra, and Viswanth, 2008, p.31 citing Smedley and Syme, 2000). The same publication emphasized that no single theory or conceptual framework was dominating research or practice in health promotion and education. The most often used common theories and models were; Health Belief Model, Social Cognition Theory, Self-efficacy Theory, The Theory of Reasoned Action and Theory of Planned Behavior, Community Organization, The Transtheoretical Model and Stages of Change, Social Marketing, and Social Support with Social Networks.

Careful considerations of these theories, as Fishbein (2000) suggested, there are only a limited number of variables that must be considered in predicting and understanding any given behavior. By focusing on these limited variables, Fishbein proposed an integrative model of behavior that attempts to bring together a number of theoretical perspectives (Fishbein, and Cappella, 2006). According to the model, any given behavior is most likely to occur if one has a strong intention to perform the behavior, and the necessary skills and abilities required to perform the behavior, and if there are no environmental or other constraints preventing behavioral performance, there is a very high probability that behavior will be performed (Fishbein et al., 2006). The model also suggests that there are three primary determinants of intention: attitude towards performing the behavior, perceived norms concerning performance of the behavior, and self-efficacy with respect to performance of the behavior. To understand why people do or do not hold a given intention (or perform a given behavior), it is important to first determine the degree to which that intention (or behavior) is under attitudinal, normative, or self-efficacy control in the population in question.

In Ethiopia many health message promotions and community health education are not research based. There are no research data describing salient beliefs about hand washing behavior of school children in rural places. In addition, proper communication and education about hand washing is very minimal. Therefore, this study aims at the application of integrative model of behavioral prediction to identify and select critical beliefs underlying the intentions to or not to wash hand with soap or ash. Then change the behavior of hand washing by applying priming theory develop persuasive education and communication of Grade 6 students of Chandba Primary School in Chilga woreda North Gondar Zone.

The researcher knows Chandba for the last 14 years when doing different project activities and providing supervision support for the school. Although soap is available in many households due to negative beliefs towards hand washing with water and soap at the three critical moments (before preparing and touching food, before eating and feeding children, and after toilet) is very poor. Regarding hand washing facilities hygiene and sanitation survey sponsored by Save the Children Norway-Ethiopia was recently conducted survey. This survey done by Abdulsemed, Minweyelet, Tenna,and Wobshet (2010) identified that of 9(47%) houses that have toilet, 3(16%) had washing facilities, 2(11%) hand washing facilities with water, and none of them had hand washing facilities with soap. This makes particularly children vulnerable to hygiene related illness. The 2009 health prevalence report data of Chilga woreda(CWFED, 2001 E.C) showed children under 5 who needed diarrhea control service were 41,765 but those who got the service were only 4,620 i.e., 11.06%. Abdulsemed et al., (2010) survey revealed the presence of a lot of water related diseases in Chilga woreda three months before the survey. The survey showed more specifically 38% diarrhea, 11% acute watery diarrhea and vomiting, 53% malaria, 25% intestinal parasites prevalent rate. The elicitation result also indicated that the normative belief prevalent in the area is that children of rural farmer do not ask for water and soap for hand washing and it is only brides and government workers who are expected to wash their hands with soap. In addition, if a child washes his or her hands, people around discourage him/her by saying “Hey! You are beautifying yourself in need of sexual partner” i.e., “Konejeh/Konejesh”.

In this study, the Integrative Model of Behavioral Prediction (Fishbein & Yzer, 2003) will constitute the principal theory, by means of which the determinants of hand washing related behavior will be determined. Fishbein and Yzer created their model by incorporating the variables of three principal theories: the Health Belief Model (Janz & Becker, 1984; Rosenstock, 1974), the Social Cognitive Theory (Bandura, 1977, 1986, 1997) and the Theory of Reasoned Action (Azjen & Fishbein, 1980; Fishbein & Azjen, 1975). All these theories have been applied to health-related behavioral research.

Fishbein & Yzer (2003) introduced the Integrative Model of Behavioral Prediction as a means to analyze how certain behaviors might be formed and changed. Fishbein and Yzer focus on the selection of beliefs, the beliefs to target in an intervention and the goals of the intervention for problematic beliefs. Moreover, their media priming theory is incorporated in this model to support positive beliefs. Research shows that the effectiveness of a health communication document is determined by several aspects of the message, the audience and the context. Most of the models for the design of health communication stress the importance of the fact that a message has to address the most important determinants and beliefs of the problematic behavior as a condition for the message to be effective (Fishbein & Yzer, 2003).

In order to achieve optimal effectiveness of the health intervention, Fishbein and Yzer state that program developers should consider the substantive uniqueness of each behavior; an individual’s specific beliefs need to be addressed to change intentions and behavior. Furthermore, they argue that the performance of a certain behavior can be predicted more precisely if one takes into consideration the context in which the behavior is performed and the target group. Finally, Fishbein and Yzer mention that a health communication document is not always an adequate tool to change some of the determinants, e.g. when people lack the necessary skills to perform a certain behavior. In this case, other interventions are needed, such as a skills training.

As the integrative model of behavioral prediction is focusing on changing beliefs about consequences, normative issues, and efficacy with respect to hand washing behavior media priming theory focuses on strengthening the association between a hand washing belief and its outcomes, such as attitude and intention toward performing the hand washing with water and soap. Both the integrative model of behavior prediction and media priming theory provide guidance with respect to the selection of hand washing beliefs to target in an intervention.

Therefore it is very important to utilize and see the complementary effects of integrative model, which predicts change in hand washing belief can result in change in intention; and media priming theory, which predicts the strengthened association of positive beliefs with hand washing behavior of primary school children. The intervention activities should include practical involvement of children starting from the planning stage and repeated multi-media message delivery, i.e., classroom teaching, group discussion, practical hand washing skill and training on how to prepare tip tap from empty plastic bottle, provision of empty plastic bottle and small amount of money to buy soap, video show, posters, new song about hand washing, and coffee ceremony.

Based on IBP and media priming the intervention activities were implemented so at the end of the month the existing hand washing practice will be changed. Some of these changes will be buying soap, prepare tip tap, wash their hand properly at the three critical moments, disseminate information to their family members as well as neighbors, and resist challenges that come from community members, develop positive belief and feel confident when washing their hands with soap.

Utilization of combined theories and implementation of multimedia message delivery to one sample participant is a challenge. The challenge demands identification of salient beliefs which predict intention towards hand washing at critical moments followed by development of persuasive message to educate the participants until they are changed. The communication messages increase accesses to information, and the more accessible it is, the more it influences attitudes, norms, and self-efficacy beliefs complimenting the integrative model.

1.2 Statement of the Problem

The complementary effects of integrative behavioral prediction model and media priming theory to develop persuasive education and communication to change hand washing practice of primary school students are used in current study. Four important assumptions are made. The first one is that there would be complementary effect between integrative behavioral prediction which suggests removing environmental barriers and provision of training result in a positive effect and media priming which suggests repeated exposure to positive media message that reinforce positive beliefs results positive impact. The second assumption is that the six IBP constructs i.e., experiential and instrumental attitudes, injunctive and descriptive norms, as well as perceived control and self-efficacy predict intention. The third assumption is that behavior beliefs are the underlining causes of the six IBP constructs. The fourth assumption is that intention is direct predictor of behavior change.

Specifically to examine the Complementarity effects of integrative behavioral prediction model and media priming theory to develop persuasive education and communication to change hand washing practice of primary school children the following questions were formulated.

1 Does beliefs that important reference persons or groups expect hand washing with water and soap has any influence on student’s perceived injective norm?
2 Dose beliefs that important reference persons or groups perform hand washing with water and soap has any influence on students perceived descriptive norm?
3 What is the strongest predictor of student’s intention to wash their hand with water and soap?
4 Does student’s positive experiential and instrumental attitude towards hand washing with water and soap have any influence intention to practice it?
5 Is their positive relationship between student’s perceived control and intention to wash their hand by water with soap?
6 Does student’s knowledge and practical skill of hand washing with water and soap have any influence on their behavior change?
7 Does student’s exposure (participation and exposure to communication) on hand washing behavior have any influence on their hand washing behavior change?
8. Does student’s intention towards hand washing with water and soap have any influence on hand washing behavior?
9 Is there complimentary relationship between IBP and Media priming to change student’s hand washing behavior?

1.3 Objectives of the Study

1. This study would helps to test the utilization of integrative model to predict hand washing behavior intention and change them by creating association between the primed variables and their outcomes on elementary school students.
2. The study has the potential to add to the current knowledge and practice by potentially explaining and experimentally testing the relative advantage to get complementary effect by using integrative model and priming theory for intervention.

1.4 Significance of the Study

The study will help as an input for development agents, policy makers, media owners Local and International NGO’s, health officials, development communicators, school administrators, teachers, and health extension workers , media organizations, school hygiene clubs and school mini-media promotion and dissemination of information to change student’s hygiene behavior. The study has the significance of helping the participants understand better ways of using locally available materials for hygiene facilities preparation. Besides, the study may serve as an insight for people who want to conduct related researches.

1.5 Delimitation and Limitations

Delimitation

The primary aim of this research is to see the presence of complementary relationship between the integrative behavioral prediction model and media priming theory in changing the existing hand washing behavior of Chandba primary school grade six students. And identify the negative and positive beliefs to be addressed through provision of hand washing facilities and exposure to repeated persuasive message. These participants particularly selected so as primary school-age is best opportunity to teach good habits early in life and their potential as agents of change within the family.

The second aim is regarding hygiene and sanitation to provide a combination of educational and participation based learning opportunities for a student’s so that they can use it in their home. With urban based living condition students are strongly influenced by normative pressure and absence of simple hand washing facilities.

Limitation

Although this research was carefully prepared, there were some unavoidable limitations and shortcomings.

First of all, because of the financial, transportation, and time limitations, this research and intervention was conducted on one school on 34 grade six students for one month. It would be better if it was done in a longer time and in many schools. Therefore, to generalize the results for large groups, the study should have involved more participants at different age and locations.

Second, the population of the experimental group is small, only thirty-four students and might not represent the majority of the students of the intermediate level.

Third, since the questionnaire designed to measure the students’ beliefs, attitudes, intention, and behavior towards hand washing with water and soap might give useful information about the immediate beliefs change through persuasive communication and participation; it seems not to provide enough evidence of the students’ sustained and long term impacts on knowledge, attitude and practice.

In addition, since the assessment of the pretest and post test on spot house observation and washing skill evaluation was conducted by the three data collectors separately, it is unavoidable that in this study, certain degree of subjectivity can be found. In fact, it would have been sort of objective if each participant member performance evaluation had been decided by all the three data collectors together.

1.6 Definition of Terms

Attitude: - refers to person’s positive or negative feelings towards performing the defined behavior. (Esther Thorson and Jeri Moore (Eds), 1996)

Behavioral beliefs: - are a combination of a person’s beliefs regarding the outcomes of a defined behavior and the person’s evaluation of potential outcomes. These beliefs will differ from population to population.(Wijk et al., 1993)

Control belief: - refers to the presence of factors that can facilitate or impede performance of the behavior control factors include required skills and abilities, time, money, cooperation e.t.c. It is a person’s subjective probability that a given facilitating or inhibiting factors will be present. (Ajzen & Gilbert Cote, 2008)

Diarrhea: - Diarrhea (acute/primary) is passage of three or more loose or watery stools in a 24-hour period, a loose stool being one that would take shape of a container. (Ejemot et al., 2008)

Efficacy belief: - refers to beliefs about capabilities of performing specific behaviors in specific situations.

Intention: - the intent to perform a behavior is the best predictor that a desired behavior will actually occur. Attitude, norm, and self-efficacy as well as perceived control influence one’s intention to perform a behavior. (Esther Thorson and Jeri Moore (Eds), 1996).

Media priming: - media priming refers to how media content can influence individuals; subsequent behavior and/or judgments related to that content (Roskos-Ewoldsen, and Carpentier, 2002).

Normative belief: - normative beliefs are a combination of a person’s belief regarding other people’s views of a behavior and the person’s willingness to conform to those views. (Ajzen & Gilbert ,2008 and AIDSCAP, 2002)

CHAPTER TWO: REVIEW OF RELATED LITRATURE

This chapter contains mainly theoretical framework which is central concept for conducting the study. The first part discusses the concept of hand washing as hygiene tool which includes magnitude of hygiene and behavior risks, impacts of hand washing practice and critical time for hand washing. In the second part behavioral theories: Theory of Reasoned Action, Theory of Planned Behavior, and Integrative Behavioral Prediction, Communication for Behavioral Change, and Complementarity Theory described. In the last part examples of interventions using communication at community and school level discussed. The literatures also include points that are hoped to shade some light to the discussion.

2.1 Hand Washing as Hygiene Tool

2.1.1 Magnitude of Diarrhea and Hygiene Related Risks

The magnitude of infection in one study (Bloomfield SF, 2009) for up to 60% of gastrointestinal illnesses, the hands are the sufficient (i.e., hands together with hand, food contact or other environmental surfaces) cause of the spread of infection in low income communities. In addition to this the study indicated that respiratory tract infections transmission via the hands could be a sufficient or component cause of up to 50% of illnesses. The Ethiopia Demographic Health Survey (EDHS, 2005) data show that 13% of children under five had symptoms of acute respiratory infection, 19% had fever and 18% had diarrhea in the two weeks preceding the survey.

In Chilga woreda where this research is done, the 2009 health prevalence report (CWFED, 2001 E.c) showed children under 5 who needed diarrhea control service were 41,765 but those who got the service were only 4,620 i.e., 11.06% , and those who needed respiratory treatment service were 47,165 but those who received the service were 3,610 i.e., 7.65 %. In another hygiene and sanitation survey sponsored by Save the Children Norway-Ethiopia (Abdulsemed Mohammed, 2010) revealed the presence of a lot of water related diseases to be prevalent in Chilga woreda three months before the survey. More specifically 38% diarrhea, 11% acute watery diarrhea and vomiting, 53% malaria, 25% intestinal parasites, and 31% other unidentified fever. This survey confirmed the disease prevalence rate of Chandiba kebele (i.e., where the school chosen for the research is found) more specifically diarrhea 10(53%), acute diarrhea and vomit 1(5%), malaria 15(79%), typhus/typhoid 1(5%), intestinal parasite 10(53%), skin disease 2(11%), and eye disease 4(21%).

2.1.2 Behavior Risk factors

In many part of the world practically tested and proved that if we change our behavior risk factors it is possible to improve hygiene related health problems. In Figure 1 behavioral risk factors easily explained by the “F-diagram”(Ram, 2010). USAIDS hygiene improvement project, (2008) publication citing Ram (2010) stated the following:

Diarrhea is preventable! The F-diagram (Ram, 2010) shows how feces are spread by poor sanitation and hygiene practice and can contaminate fingers, fluids, floors/fields, and flies, and that is how diarrhea germs in feces end up in our food or enter our mouths in other ways. Latrines can help stop transmission via fluids (drinking water) and fields and floors, and some improved latrines may also break the flies’ routes, but no type of latrine can prevent contamination of hands and fingers. Good hygiene practices are needed for this. Three key hygiene practices can block the feces transmission pathways and prevent diarrhea:

1. Disposing of feces safely
2. Drinking safe water
3. Washing hands with soap at critical times.

illustration not visible in this excerpt

Figure 1: The F-Diagram (Ram, 2010)

But there are different factors that affect hand washing behavior. Environmental factors that influence hand washing practice as Curtis Danquah, and Aunger (2009) mentioned are divided into social, biological, and physical factors which either positively or negatively influences it. Curtis elaborated them as:

Physical factors include water, soap, and toilets. Their presence, abundance and place where they are available are important issues. Social factors includes local cultures, beliefs, traditions and norms which are emanated through social structures such as the family, neighbors, local social organizations, government-health workers, schools and mass media. Who control the family soap budget is important issue in many cultures. In some it is the father who is responsible to buy soap. Hand washing with soap is rarely promoted in media. Biological factors include lack of time and energy for hand washing, and being so busy that hand washing is forgotten. (p.13)

Wossen (2010) mentioned changing deep-seated, private and culturally-embedded practice such as hand washing is a difficult process. According to Wossen finding many people belief that wash their hands when hands got dirty after contact with cow’s dung, oil, fat or bad smell, the belief that hand remain visibly clean after visiting latrine is very strong. And also another constraining belief is the general acceptance that child diarrhea is an inevitable part of child growth. Fear of disease generally did not motivate hand washing, except transiently in the case of epidemics (Curtis et al., 2009).

The study conducted by Curtis et al., 2009., stressed that though increasing resources are being brought to bear on the problem, changing deep-seated, private, morally charged and culturally embedded hygiene practice is a difficult and uncertain process. By another research (Allegranzi, Memish, Donaldson, and Pittet, 2009) an extensive litrature research,experts and religious authorities form the 7 main religions world wide consultation done to investigate religiocultural factors that may potentially influence hand hygiene promotion results religious faith and culture can strongly influence hand hygiene behaviour, so interpretation of hand gustures and the concept of visbly dirty hands impacts of religion and culture must be taken in to consideration during intervention.

By another research (Halder et al., 2010) the low hand washing behavior of Bangladesh rural people during key critical times by soap is due to deeply-rooted belief of considering water as a potent purifying agent. In another research (Curtis et al., 2009) the most appropriate time to use soap for hand washing was often said to be after eating, to remove stick food residues-the least important occasion for hand washing with soap, from hygiene point of view. Examination of possible relationship between knowledge of hand washing with soap and hand washing practice by Wossen (2010) in Adama area shows that high knowledge is accompanied only by 10% of consistency which is lower than those with low knowledge (14%). Wossen interpretation of the multivariate analysis shows no association between knowledge about hand washing and its corresponding practice indicating that knowledge cannot be a determinant of how a person will behave in relation to hand washing. This fact verified in another survey conducted in Alaba and Mirabe Abaya area (RiPPLE, 2008) the result shows regarding hand washing facilities and practice, good(declared) knowledge on hand washing but actual practice seems poor; hand washing facilities present in 82% of households but most(64%) located inside the house; only 65 near the latrine. In Bangladesh evaluation conducted on 20,564 people in selected 100 communities key time observation 55% of study subjects wash their hands, though in only 350 episodes (1.7%) they did wash both hands with soap or ash. (HBS, 2008)

Even though knowledge is not a serious factor for hand washing behavior improvement, one of the key constraints is the affordability of soap as Bloomfield (2009) mentioned on the research conducted in low income communities. The research shows in extreme settings where people are poor and at highest risk for morbidity and mortality from infectious disease, the greater need is for families to spend what little income they have on food. The research recommends for such communities the use of clean and dried soil and ash for hand washing is preferable to using water only, because it is more effective.

The survey result of Chandba kebele in Chilga woreda( where this research is carried out) conducted by Abdulsemed and his research group(2010) shows 9 houses(47%) from the total included households have toilet. Of these 3(16%) had hand washing facilities, 2(11%) had hand washing facilities with water, and none of them had hand washing facilities with soap. The results also indicated the low level of knowledge in Chandba, 11(58%) know need of washing hands with soap, 8(42%) know critical moments of hand washing.

According to the research conducted by Ejemot et al., (2008), hand washing may require infrastructural, cultural, and behavioral changes, which take time to develop, as well as substantial resources ( e.g., trained personnel, community organization, provision of water supply and soap) confirmed through several research conducted in the field.

2.1.3 Critical Time for Hand Washing

In the research conducted in Adama rural community on mothers of under 5 children (Wossen, 2010) indicated that practice of hand washing with soap is a little higher after defecation(18%) and after handling tools(15%) and lower before handling/preparing food(12.4%) and before feeding the child(11.9%). Regarding hand washing with soap after cleansing child faces Wossen mentioned that the frequency is 19%. In the case of school children only 33.6% reported always or very often wash their hands with soap and clean water before eating and after using the toilet.(Lopez-Quintero, 2009) The reason for this lower level of hand hygiene practice is due to lack of parent to teach their children at early stage. This is verified by review results of researches (Curtis, 2009) from 11 countries it was indicated that hand washing habit were generally not inculcated at an early age.

The organisms causing diarrhea can be transmitted from infection feces to people through food and water, person to person contacts (Ejemot et al., 2008). In particular, Ejemot added that, hand contact with ready-to-eat food (i.e., consumed without further washing, cooking, or processing/preparation by the consumer) represents a potentially important mechanism by which diarrhea-causing pathogens contaminate food and water. And also important are exposure of food to flies and consumption of contaminated water.

In 2010 Australian Aid, Water and Sanitation Hygiene (WASH), Hand washing with soap fact sheet (Water and Sanitation Hygiene(WASH), 2010) after analyzing important research documents on the status of hand washing from all over the world made the following summary:

The simple action of hand washing with soap is an integral part of the Australian aid, Water and Sanitation Hygiene (WASH), program helping to achieve the Millennium Development Goals (MDGs).

The challenge is to make hand washing with soap an automatic behavior performed in homes, schools and communities worldwide. In developing countries this is literally a life and death issue. Hand washing facts:

Hand washing at critical times including before eating or preparing food and after using the toilet can reduce diarrhea rates by almost 40 per cent.

Hand washing with soap can reduce the incidence of acute respiratory infections by around 23 per cent.

Pneumonia (a lower respiratory infection) is the number one cause of mortality among children under five years old, taking the lives of an estimated 1.8 million children per year.

A study has assessed the effect of hand washing promotion with soap on the incidence of pneumonia and found that children younger than five years in households that received plain soap and hand washing promotion had a 50 per cent lower incidence of pneumonia than those households that did not have soap.

Hand washing can be a critical measure in controlling pandemic outbreaks of respiratory infections. Several studies carried out during the 2006 outbreak of severe acute respiratory syndrome (SARS) suggest that washing hands more than 10 times a day can cut the spread of the respiratory virus by 55 per cent.

Hand washing with soap has been cited as one of the most cost-effective interventions to prevent diarrheal related deaths and disease.

A review of several studies shows that hand washing in institutions such as primary schools and day care centers reduce the incidence of diarrhea by an average of 30 per cent.

Rates of hand washing around the world are low. Observed rates of hand washing with soap at critical moments, that is, before handling food and after using the toilet, range from zero per cent to 34 per cent.

A recent study shows that hand washing with soap by birth attendants and mothers significantly increased newborn survival rates by up to 44 per cent.

The lack of soap is not a significant barrier to hand washing with the vast majority of even poor households having soap. Soap was present in 95 per cent of households in Uganda, 97 per cent of households in Kenya and 100 per cent of households in Peru.

Water alone is not enough and soap is rarely used for hand washing. Laundry, bathing and washing dishes are seen as the priorities for soap use.

New studies suggest that hand washing promotion in schools can play a role in reducing absenteeism among primary school children. In China, for example, promotion and distribution of soap in primary schools resulted in 54 per cent fewer days of absence among students compared to schools without such an intervention.(p.1&2)

2.1.4 Hand washing Practice

A lot of researches conducted starting in the 20th to evaluate the effectiveness of soaps and other detergents. For instance, a study by Norton (1922) was done in the examination of 12 different samples of toilet type to the most expensive so-called germicidal or antiseptic soap.

In the experiment hands were washed by different soaps in sterile water at Abbildung in dieser Leseprobe nicht enthalten C and then rinsed. From the 12 wash water plate culture result indicated that ordinary toilet soap removes the largest number of bacteria from skin. Borges et al., (2007) however emphasized that washing with waster and soap was effective in reducing the hand contamination only for healthy hands not for damaged hands. In another evaluation study done on 1932 subjects by Chamorey et al.,(2010) where individual and environmental risk factors( age, sex, use of a protective agent, constitutional factors, personal factors, and a number of consecutive working days) of whether that disinfection with an alcohol-base hand rub better tolerated than classic hand washing with mild soap and water. The result shows that traditional hand washing with soap is a risk factor for dryness and irritation, whereas use of alcohol to wash cause no skin deterioration and might have protective effect, particularly in intensive use. This result faced strong argument by many researchers.

According to Wijk, Christine, Murre, and Tineke (1993), hand washing is only effective when hands are rubbed sufficiently and preferably with cleaning agents like soap, ash, soil or certain types of leaves. Just pouring water over hands, as is sometimes done, is not effective in removing pathogens. In this regard, Ejemot et al., (2008) mentioned washing with soap and water not only removes pathogens mechanically, but may also chemically kill contaminating and colonizing flora making hand washing more effective as verified by Han(1998),Shahid(1996), and Rotter(1999) independent research. Regarding the use of water Ejemot suggested washing hands with soap under running water or large quantities of water with vigorous rubbing was found to be more effective than several members of a household dipping their hands in the same bowl of water (often without soap) identified by Kaltenthaler (1991) research. Furthermore, as Bloomfield et al., (2009) suggested that the use of rubbing agent is important and the nature of the agent is a less important factor. Their research indicated that the key component of the hand washing process is the mechanical rubbing of the hands and that soap is more effective than soil and ash because soap users tend to rub their hands more and use more water to rinse away the soapy feeling on their hands.

In many part of the world ash and mud are used for hygiene purpose including for hand washing. Bloomfield et al., (2009) mentioned that wood ash, when freshly produced through the burning of wood, must be sterile. However, where ash is allowed to accumulate either in, or in the vicinity of the home, it has the potential to become contaminated with pathogens, either from human or animal feces or from waste water discarded around the home. There is however no data to show whether and to what extent as, use of contaminated soil, mud or ash for hand washing, may be a source of microbial infection or potential toxic effect. Bloomfield et al., (2009) quoting Hoque and Briend a 1991 evaluation study mentioned the relative efficiency of hand washing using ash, soap, mud or plain water, in group of 20 women living in slum of Dakar in Bangladesh. Each woman washed her hands using of the washing agents and the efficiency of the process was assessed by comparing fecal Cliform (a type of Bacteria) counts from post washing hand samples. Result showed that, for 60 %( 12) of women who did not wash their hands, the hands were contaminated with fecal Coliforms. The proportion of positive counts was similar for ash and mud 40%(4), with water 40%(8) and with Ash 15%(3) where none of these differences were statistically significantly(p-value <0.01) from each other. In 1995 Holque et al., as cited in Bloomfield reported a study of women in rural Bangladesh evaluating the different hand washing process indicated that of 90 subjects observed wash their hands after defecation, 38% used mud, 2% used ash, 19% used soap, and 41% used water only without a rubbing agent. In another research presented in South Asia Hygiene Practioners’ Workshop 1-4 February 2010 Danquah (2010) mentioned the use of ash greater than 66% of the time during the observation period was 9% and 14% respectively after cleaning child anus and after defecation.

In many observational researches measuring and interpretation of hand washing practice is a problem. But Larson and Lusk (1985) presented two models. In one tested model of hand washing interpretation and scoring to make consistent and reproducible result a series of test. In this model vigorous frictions was defined as increasing visible movement of both arms up to the elbow and an audible sound of rubbing (unless the flow of water was too loud to allow one to hear the sound). Minimal friction was defined as an absence of rubbing of hands together the soap was applied. But this model has got difficulty in many ways. Do you to this fact they developed the second more comprehensive model. To demonstrate accurately and in reliable ways of evaluation the second tool is better because it includes all the 7 minor details which are described, Larson and Lusk (1985) are soap, splashing, friction (rubbing), surface covered, hand position, rinse, and drying.(Table in Annex 4)

2.1.5 Impact of Hand Washing

Ejemot et al., (2008), in their research on about 7711 participants to evaluate the impact of interventions to promote hand washing on diarrheal episodes in children and adults, fourteen randomized controlled trials in 29% reduction in diarrhea episodes of high income countries and a 31% reduction in low-or middle-income countries providing clean water. Similarly, Ejemot et al.,(2008) quoted Clasen (2006); found a 27% protection from diarrhea related problem. Two meta-analysis of hand washing indicated its effectiveness. Ejemot et al.,(2008) described these meta-analyses one citing Curtis 2003, the effectiveness of hand washing with soap in community-based studies and estimated that it could reduce diarrhea risk by up to 47%; and the other citing Fewtrell 2005, which examined a range of water, sanitation, and hygiene interventions in low-and middle-income countries estimated 44% reduction of diarrhea. In the case of school based studies, Lopeze-Quintero (2009) students with proper hand washing behavior were less likely to report previous-month gastrointestinal symptoms(OR=0.8;95% CI=0.6,0.9) or previous year school absenteeism(OR=0.7;95% CI=0.6,0.9).

Several candidate strategies for promoting hand washing with soap identified from 11 countries research reviewed by Curtis et al., (2009) include creating social norms, highlighting disgust of dirty hands and teaching children hand washing with soap as a good manners. Among these status, nurture, comfort, habit, privacy, affiliation, attraction, fear and motivators like dirty, disgust, foul, or smelly of feces, urine, bodily fluids and rotten or dead items are discussed in the document. Most of them have got positive impact for hand washing, but in very rare areas they do have different meanings. For instance, status- being seen to be clean could lead to being admired and respected, and a clean child was regarded as an ambassador from the family to the society at large. On the other hand, being labeled as ‘dirty’ was thought shameful and to be avoided at all costs. However, some respondents in Kenya and Uganda raised the concern that if their hand washed with soap, they might be seen as being too clean and different from other people, as trying to get above themselves and people hate you.

From the years of researches it was known that hand washing is one of the simple and effective means to improve human health. The challenge is to find effective ways of getting people to wash their hands appropriately and habitually use soap when they wash their hands (HBS, 2008). This demands the proper selection of theoretical frame works for behavioral prediction as well as intervention.

2.2. Theoretical Frameworks

2.2.1. Theory of Reasoned Action (TRA)

The work linking general attitudes to specific action of specific behaviors have advanced our understanding of the attitude-behavior relation and have demonstrated the importance of attitudes as determinants of behavior. (Ajzen & Fishbein, 2005) The model is based on the ideal of concept integration in that a set of salient beliefs about a concept becomes organized in the mind as a cognitive structure that is a complex network of integrated beliefs that makes up attitude. (Thorson and Moore, 1996) “A reasoned action approach”, Fishbein (2008), stated that “to the explanation and predication of social behavior assumes that people’s behavior follows reasonably from their beliefs about performing that behavior.” (p.835). In addition to this, Ajzen & Fishbein (2005), reasoned action approach suggests that change behavior-specific belief in a much more effective strategy than targeting a background factor, such as prejudice. According to this approach if we change behavior specific behavioral, or normative beliefs strongly prejudiced individuals may simply find other beliefs (or reasons) not to do the action.

To use reasoned action approach first one has to clearly define (and describe) the behaviors in which one is interested. Which means not make the behavior a class of behavior (category) or goal. Because it is easier to predict whether one will or will not engage in a particular behavior than whether one will or will not engage in a class of behaviors or attain a given goal (Fisbein,2008). He added that the definition of a behavior involves 4 elements which is the behavior can be viewed as involving an action directed at a target, performed in a given context at a certain point in time. Fishbein emphasized that irrespective of how one choose to define a behavior, once that behavior has been defined, a reasoned action approach suggests that a change in any one of these elements changes the behavior under consideration. This indicates that one does not perform the same behavior in different in different context but instead performs different behaviors. In his principle of correspondence Fishbein suggests that intention and behavior should be measured at equivalent level of generality or specificity which indicates the correlation of their measures.

2.2.2 Theory of Planned Behavior (TPB)

The Theory of Reasoned Action (TRA) omits the fact that behavior may not always be under volitional control and the impacts of past behavior on current behavior.(Munro et al., 2007) Because of this, Barbara and Karen (2005), Ajzen and Driver extended the theory to include perceived behavioral control and termed this the Theory of Planned Behavior(TPB). They added this construct to account for situations in which people’s behavior, or behavioral intention, is influenced by factors beyond their control. They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it. Barbra and Karen (2005) mentioned that behavioral control represent the perceived ease or difficulty of performing the behavior and is a function of control belief. Conceptually it is very similar to self-efficacy and includes knowledge of relevant skills, experience, emotions, past track record and external circumstances.

2.2.3. Integrative Behavioral Prediction (IBP)

Integrative Behavioral Predication (IBP) includes constructs from both Theory of Planned Behavior (TPB) and Theory of Reasoned Action (TRA), as well as constructs from other excellent theories of behavior. IBM was developed through discussions and consensus among major behavioral theorists and has been modified through empirical work over the past decades (Glanz K et al., 2008). Glanz added that IBM as noted in TPB and TRA, other demographic, personality, attitudinal and individual difference variables; which are considered as distal variables, may be associated with behaviors, but their influence is indirect, through theoretical constructs. Thus, certain demographic groups may be more likely than others to engage in the behavior, because there are demographic differences on the proximal variables. Similarly Fishbein & Yzer (2003) (cited in Duijn, 2007) indicated that integrated model shows that a number of distal variables (i.e., demographic variables, culture, perceived risk, etc.) and also media exposure (Fishbein & Cappella, 2006) are part of the model. These variables do not directly influence behavior, but they influence the underlying beliefs structure and, as a consequence, the proximal variables.

As mentioned in the discussion of TPB Tavousi et al., (2009), proposed two distinct constructs (perceived self-efficacy and controllability) in perceived behavioral control (PBC) by several researches. Tavousi et al., (2009) further discussed their idea as:

The perceived self-efficacy was defined as “the belief of ability of behavior performance” or “the ease/difficulty of behavior performance”, and controllability was defined as” control beyond behavior performance”, but in the research self-efficacy was defined as “people’s beliefs about their capabilities to produce performances that influence events affecting their lives”, and PBC (as the same controllability) was defined as “control beyond behavior performance”. (p.151)

Many researchers on self-efficacy confirmed that, we can predict that people will be more likely to perform those interpersonal behaviors that they believe they can perform successfully (Locke & Sadler, 2007). In addition to this studies which applied TRA/TPB to explain a variety of health behaviors supported perceived control as a direct predictor of both intentions and behaviors. Glanz et al., (2008) says; “However, most studies have used direct measures of perceived control, rather than computing perceived control from measures of control beliefs and perceived power concerning specific facilitators and constraints. The few studies that have measured control beliefs (indirect measure) found them to be important predictors of intentions and behaviors. Clearly, if perceived behavioral control is an important determinant of intentions or behaviors, knowledge of the effects of control beliefs concerning each facilitator or construct would be useful in the development of intention.” (pp 76-77)

Researchers recommend the better use of integrated behavioral prediction model that includes construct from TRA/TPB, as well as from other influential theories (Figure 2). Glanz et al., (2008) described his recommendation by discussing about IBP determinants; the most important determinant of behavior in the IBM is intention to perform the behavior similar to TRA/TPB. Without motivation, a person is unlikely to carry out a recommended behavior. Glanz et al.,(2008) continues their description about other components of IBM, among four other components that directly affect behavior three of them are important in determining whether behavioral intentions can result in behavioral performance. First, even if a person has a strong behavioral intention, he needs knowledge strong behavioral intention; the person needs knowledge and skill to carry out the behavior. Second, there should be no or few environmental constraints that make behavioral performance very difficult or impossible. Third, behavior should be salient to the person. Finally, experience performing the behavior may make it habitual, so that intention becomes less important in determining behavioral performance for that individual, as sited from Triandis (1980), and Becker (1974).

illustration not visible in this excerpt

Figure 2: Integrated Behavior Model.( Background influence taken from Fishbein & Cappella 2006,p.S2 and IBP taken from Glanz et al., 2008, p.77)

Integrative Behavioral Prediction (IBM) Construct Categories

According to Integrative Model behavioral intention is determined by three construct categories. Glanz et al., (2008) pointed out each categories, the first is attitude toward the behavior, defined as a person’s overall favorableness or unfavorableness toward performing the behavior. Attitude is a composed of affective and cognitive dimensions. Experiential attitude or affect is the individual’s emotional response to the idea of performing a recommended behavior. Individuals with strong negative emotional response to the behavior are unlikely to engage in it. Instrumental attitude is cognitively based, determined by beliefs about outcomes of behavioral performance, as in the TRA/TPB. Second, perceived norm reflects the social pressure one feels to perform or not to perform a particular behavior. Fishbein (2007) indicates that subjective norm (normative beliefs about what others think one should do and motivation to comply), may not fully capture normative influence. In addition, perceptions about what others in one’s social or personal networks are doing (descriptive norm) may also be an important part of normative influence. This construct captures the strong social identity in certain cultures which is indicator of normative influence. Third and finally, personal agency, described by Bandura (2006) as bringing one’s influence to bear on one’s own functioning and environmental events. In IBM, personal agency consists of two constructs-self-efficacy and perceived control. Perceived control, as described previously, is one’s perception of the degree to which various environmental factors make it easy versus difficult to carry out the behavior. In contrast, self-efficacy is one’s degree of confidence in the ability to perform the behavior in the face of various obstacles or challenges. (Glanz et al., 2008)

Glanz et al., (2008) added that the relative importance of the three categories of theoretical constructs (attitude, perceived norm, and personal agency) in determining behavioral intention may vary for different behaviors and for different populations. Thus, to design effective interventions to influence behavioral intentions, it is important first to determine the degree to which that intention is influenced by attitude (experiential and instrumental), perceived norm (injunctive and descriptive), and personal agency (self-efficacy and perceive control). And the understanding of the underlying determinant beliefs of those constructs is essential. These beliefs are: for experiential attitudes feelings about the behavior, instrumental attitudes are a function of beliefs about outcomes of performing the behavior, perceived norms are a function of normative beliefs (i.e., beliefs that specific individuals or groups think one should perform the behavior), perceived control is a function of control beliefs about the likelihood of occurrence of various facilitating or constraining conditions weighted by the perceived effect of those conditions in making behavioral performance easy or difficult, self-efficacy is the stronger one’s belief that one can perform the behavior despite various specific barriers, the greater one’s self-efficacy about carrying out the behavior.

A further elaboration of this model, Glanz et al., (2008) suggests that the relation between the three factors (Attitudes, subjective norms, and self-efficacy) could be interactive instead of linear. In this case intentions will be positive if self-efficacy is high and either or both attitude and social norms are positive as well. They are complementary to each other. The model explains behavioral intention and behavior in which elements of Bandura’s Social Learning theory and Fishbein-Ajzen model are integrated. So that it is called Integrative Model of Behavioral Prediction. These integrative models, the theoretical variables contained in the model have been tested in over 50 countries in both the developed and the developing world (Fishbein, 2000).

Fishbein & Yzer (2003) cited in Duijn (2007) focus on the selection of beliefs, the beliefs to target in an intervention and goals of the intervention for problematic beliefs. Moreover, their media priming theory is incorporated in this model to support positive beliefs. The short coming of this model, however, is that Fishbein and Yzer do not deal with the question how the problematic determinants of behavior should be changed. They state that there are no useful theories available to describe how the problematic determinants can be changed effectively.

Standard models of behavior change such as TRA, TPB, Health Belief Model or extensions of it which focus on cognitive and rational reasons for hand washing have shown significant importance for promotion (Curtis et al., 2009). These theories should applied in conjunction with broader disciplinary approach to behavior change, which embraces emotional, habitual and cultural factors, as well as rationality is needed. This is supported by Glanz et al., (2008), in this way IBM can be compliment the use of other theories of change and there by improve health behavior research and practice. It is likely that the strongest interventions will be built from multiple theories. In this regard, Glanz added that other communication and behavior change theories should be used (together with IBP) to change those target beliefs.

2.2.4 Communication for Behavior Change

Martin Fishbein (2008) emphasized the need for communication models for behavior change by saying; “we do not need ‘new’ behavioral theories. What we need, however, is for people to better understand and to correctly use existing theory. Even more important, we need better theories of communication efforts to understand the factors influencing whether a given piece of information will be accepted or rejected.”(p.843)

Moemeka (1994:11) (cited in Ephrem, 2007) stated the about communication; Hierbert et al., defined communication as the exchange of ideas and that “It is not the mechanical transfer of facts and figures as the mathematical model of communication” of Shannon and Wever, 1949. Herbert et al., added that communication is also not taking at people but an interactive process that works in circular, dynamic and ongoing way. Communication, according to Moemeka, (cited in Ephrem, 2007) is talking with people-a process with no permanent sender and no permanent receiver. “In the process of communication, the roles of sending and receiving changes hands depending on who is talking and who is listening. This implies freedom, equality and shared interest”. (p.6)

2.2.4.1 Communication Strategies

To get a maximum impact, according to Flay and Burton (1990) (cited in Hyndman B. 2001) communication strategies has to maximize positive interpersonal communications about priority health issues, particularly among the local residents. The more people talk about (and therefore think about) an issue, the greater are the chances of change. Here are some of communication methods:

Diffusion Innovation Method

Diffusion innovation, as described in Tigist (2010) is one of the known methods in which several scholars suggested it in bringing about change at the community level. It describes how new ideas and opinions are disseminated in order to change attitudes and behaviors of people in a community. Servaes (1999) as cited in Tigist (2010) mentioned the criticism of innovation of diffusion as a model which assumes as a new idea/innovation always comes from the outside not from within. Servaes noted there is a need for an understanding for the existing local beliefs, traditions, culture and interpretation life before any new idea or innovation takes place. This point strengthens the need for behavioral prediction (using IBP) before the intervention that this paper is intending to do.

Persuasive Communication

According to Petty & Priester (1994) (cited in Fahmy & Wanta, 2007) in order for an effective influence to occur, by persuasive communication to attitudinal change, a person needs to be exposed to new information. Further Petty & Priester mentioned audience’s motivation and the ability to think about this message of new information determine how much processing will occur. And persuasive communication is more effective when recipients are motivated and are able to process attitude-relevant information than when they are not. Researches indicated that an important goal of persuasion strategies has been to enhance processing by increasing personal relevance of the communicated message.

Fahmy & Wanta (2007) (citing Stuaffer, Frost & Rybolt, 1993) stated that, for persuasion to takes place information processing must occur. They added the mechanisms of persuasion are study, repetition, connection to prior knowledge and elaboration facilitates information retrieval and recall. They elaborated the process that attitudes influenced by information cues which are important determinants of persuasion.

Stuaffer, Frost & Rybolt (2007) confirmed the suggestion by scholars that repetition and argument strengths are directly related to efficacy and attitude change. Past studies found the redundant features may increase the efficiency of a communication message (cited Severin & Tankard, 2001) and may create stronger persuasive arguments. Fahmy & Wanta (2007) (citing Benoit and Smythe, 2003) explain attitude change based on thoughtful persuasive arguments in a message is likely to persist longer than attitude change based on superficial reflections or shortcut cues. They concluded in sum, past literature suggests repetition (citing Sinclair, Mark, & Clore, 1994) and argument strengths (citing Mitchell, 2000) are directly related to efficiency and attitude change.

Media Priming Method

The original definition of priming effects of news coverage given by Iyengar and Kinder’s (1987) as cited in Young Mie Kim (2002) is “changes in the standards that people use to make political evaluations”. Priming effect has association effect and accessibility effect to generate association between primed constructs and other constructs, stimuli, or judgmental context (Young Mie Kim ,2002 citing Higgins, 1996; Higgins, 1981).

Young Mie Kim (2002) discussed the problem of utilizing the implications of priming effect in psychology in the following way:

Despite their popularity, studies on news media’s priming effects have not full advantage of the implications of priming studies in psychology. First of all, studies on the news media priming effect have tested only pressure patterns of accessibility effects (i.e., a comparison of the evaluation of a particular issue, which is extensively covered by news media), failing to identify potential associative attitude structures, even though theories in psychology have clearly emphasized the association effects as well as the accessibility effects of priming. (pp. 169-770)

People have many sources of information that they can use at any given time and all of this information can play important roles in judgment making at one time or another. Kim described the other way effect of priming as when people decide the primed concept is not appropriate for making a judgment; they attempt to retrieve an alternate from their existing attitude or knowledge structure. Cues in a priming setting can prompt individuals to use or not use primed concepts, which helps with retrieving prime-independent information.

Small group or class communication

Hybles and Weaver (2001) as cited by Tigist (2010) indicated that effective small group’s communication have certain characteristics in common:

A sense of solidarity, an ability to focus on their task, and a task that is appropriate for their particular group. In addition, effective group must be of a workable size; from 3 to 13, must meet in appropriate surroundings with suitable seating arrangements and must inspire its members to feel cohesiveness and commitment. ( p.302).

According to Glanz et al., (2009) group of educational setting (e.g classes) is strong in presenting an intensive, interactive experience but week in their capacity to reach a high proportion of the population. Mass media, on the other hand, are strong in their capacity to reach large numbers of people, but weaker in their capacity to provide an intense, interactive experience. Glanz recommended that campaign planning framework seek to offset this individual weakness through the strengths of diverse strategies.

Synergy: Multimedia effects on attitude change

Thorson and Moore (1996) in their book mentioned about synergy as maximum impact is created through synergy- the linkages that are created in a receiver’s mind as a result of messages that connected to create impacts beyond the power of any one message on its own. Repeatedly expose the audience to a message for enough times so that they understand, learn, and file it away in memory, and also familiarity with complex stimuli produces more positive response, although increased familiarity with simple stimuli can produce boredom. Thorson and Moore (1996) elaborated it as: synergy suggests that an entire structure of messages with its links and repetition creates meaning and impact even in situations where there might be little attention paid. Integration occurs at several levels in strategy and planning, in coordinated uses of traditional and nontraditional communication channels.(p.334)

They added that synergy exists through the function of memory-messages that are conceptually integrated and that repeats essential units of meaning over time through different channels and from different sources come together to create coherent knowledge and attitude structures in the receiver. Message elements primarily words and pictures are the creative tools used to mold and shape the concept which evolves through a variety of exposures and impressions built up over time. Because of its selective perception of message, complex thoughts made up of likes and dislikes direct relation with attitude change, Thorson and Moore (1996) concluded that the concept of integrated messages in multi-channel environment clearly offers an area for the logical extension of Fishbein work. Which indicates the value of information reinforcement through multimedia communication, means that people learn better when they hear and see the same message at the same time, a theoretical perspective that informs and confirms the notion of integrated communication.

Development Communication

Wilkins (2000) as cited in Efrem (2007) understands development communication as “the strategic application of communication technologies and processes to promote social change.” On the other hand, Servaes and Malkhol defined development communication as the sharing of knowledge aimed at reaching a consensus for action that takes into account the interests, needs and capacities of all concerned where interpersonal communication too must play a fundamental role. Ephrem added (citing Waisbord,2000 cited in Waisbord, 2005) Waisbord idea in defining development communication which are empowerment, integrating ‘top-down’ and ‘bottom-up’ approach, a ‘tool-kit’ approach, combining of interpersonal communication and multimedia activities, the last one focus on individual and environmental factors.

2.2.4.2 Communication and Attitudinal Change

According to Thorson and Moore (1996) referring to Fishbein theory which hypothesizes that belief lead to attitudes although he does not locate the beliefs/attitude structure in terms of a more complex information processing model. Thorson and Moor added that Fishbein familiar algebraic model that specifies the relationship between this set of beliefs and a concept provides”theoretically integrated set of measures of cognitive effects. . can be used to measure the multiple effects of a particular communication message on cognitive structure variables.” Cognitive processing is clearly a mediating factor in attitude function.

As Ajzen, & Gilbert (2008) mentioned it beliefs may be formed as a result of direct observation, they may be self-generated by way of inference processes, or they may be formed indirectly by accepting information from such outside sources as friends, television, newspaper, books, and so on. Some beliefs persist over time, other weakens or disappears, and new beliefs are formed. It was confirmed in the case of purchased behavior Thorson and Moore (1996) information from advertisements, as well as from other sources, is integrated into an attitude structure and this structure determines both intention to purchase-the attitude-as well as the actual purchase behavior.

In this regard Fishbein theory salient beliefs are as Thorson and Moore (1996) mentioned those activated from memory to become a consideration in a particular situation. If such beliefs are anchored in a person’s memory, then that means the person must have heard something relating to it previously. In other words, salient is built up over time through repletion as stored knowledge. They added that a person may have a variety of beliefs associated with an object and the best measure of that person’s attitude comes from averaging across this set of beliefs.

To influence health behaviors, messages (from interpersonal to mediated) need to be relevant and compelling, with-related decisions and adopting health-preserving behaviors (Sparks, 2010). As Manfredo (1992) mentioned a successful persuasive communication designed to change a certain behavior must contain argument that will bring about a change in the antecedent intention. He added TPB goes beyond the question of intended action, taking into account the possibility that the behavior of interest may not be completely under volitional control. So they suggested that to be successful, the message may have to provide information that will enable the receiver to gain volitional control and overcome potential obstacles to performance of the behavior. Which means the persuasive communication designed to influence intentions (and thus also behavior) can be directed at one or more of the intention’s three determinants: attitudes, subjective norms, and perceived behavioral control. Manfredo added to do this the message is then conducted such that it will ether in their strength or their evaluations, or introduce new beliefs into the belief system.

According to Alfred (1991) enhanced self-efficacy expectations often seated as a greater intention or self-confidence regarding adoption of a desired new behavior, is another function of modeling: if the model can do it( e.g., perform a new skill), the observer can do it as well. Modeling is also important in conveying norms, communicating the idea that “everyone is doing it”.

Punnahitanond and Nelson (2009) conducted a research entitled “A Positive Youth Development Media Campaign Targeting Youth and Parents" benefits Fishbein Integrative Model by testing its predictive and explanatory value in the area of mass communication and youth development. The findings testify the transferability of both assets framework and Fishbein model to a collectivist culture. In this experimental study the media message positively influenced subjects self-efficacy for behavior change (i.e., asset building) during the post exposed period (two weeks).

2.2.4.3 Health Communication Principles

Barbara and Glanze (2005) indicated about communication relation to health message in this way:

Communication theory explores “who says what, in which channels, to whom, and with what effects.” It investigates how messages are created, transmitted, received, and assimilated. When applied to public health problems, like hand washing behavior change, the central question the theory of communication seek to answer is, “How do communication processes contribute to, or discourage, behavior change?” Public health communication is the scientific development, strategic dissemination, and evaluation of relevant, accurate, accessible, and understandable health information, communicated to and from intended audiences to advance the public health. (p.29)

Leading communication scholar and editor of Health Communication, Teri Thompson on his book in titled the Nature and Language of Illness Explanation published in 2000, as cited in Sparks (2010) indicated that health communication deals with health care related environments that give meaning to health status by assuming and defining its cause. Sparks added that health-related information can be constructed in terms of either gains (benefits) or losses (costs). But which framework is better? The answer depends on whether the target health behavior or an illness protection behavior. A detection behavior involves uncertainty where as protection behaviors typically lead to relatively certain outcomes.

According to Barbara and Glanze (2005) public health communications can increase knowledge and awareness of a health issue; influence perceptions, beliefs, and attitudes that factors into social norms; prompt action; demonstrate or illustrate healthy skills; increase support for services; debunk misconceptions; and strengthen organizational relations. Hyndman (2001) ( cited from Israel, 1985, Cohen and Syme, 1985, Gottlieb, 1987, Eng,1989) mentioned that the health benefits of empowerment are positive health impacts including enhanced helping abilities among community members, increased levels of social support, enhanced copping capacities, increased susceptibility to illness. Moreover interpersonal health communication scholars mentioned in Sparks (2010) tends to focus relationships, such as those between providers and patients, or they study how everyday relationships (i.e., family members, co-workers, and friends) impact our health. Others focus on social influence and they devote their efforts to understand how health messages and campaigns can be improved in terms of leading to health behavior changes for large group of people.

Brian Hyndman (2001) citing from Boeren (1992) suggests that communication channels, both interpersonal and media, are used to make community group members aware of shared health concerns and to mobilize them to action. He added citing Farquhar et al., (1977) that evaluations of “media-alone” interventions have consistently found little or no impact on behavior. By contrast, significant changes in health behavior have occurred when media appeals were combined with community-based activities. Barbara and Karen (2005) explain media effects and its relation with heath issues in the following way:

Media effects: the outcomes of media dissemination of ideas, images, themes, themes, and stories are called media effects. The influence level of message depends on several factors: characteristics of target audiences (e.g., their readiness for change, the ways they process information), the complexity of the heath issue, the presence of competing messages, and the nature of the health message influence the relationships between exposure to a health message and an outcome effect. Repeated exposure to a message, especially when it is delivered through multiple channels, may intensify its impact on audience members. (p.30)

Barbara and Glanze (2005) continue their discussion about the possible paths through which a health communications message can influence someone’s beliefs and/or behaviors are: immediate learning (people learn directly from the message), delayed learning (the impact of the message is not process until sometime after it has been conveyed), generalized learning( in addition to the message itself, people are persuaded about concepts related to the message), social diffusion(messages stimulate discussion among social groups, there by affecting beliefs), and institutional diffusion (messages instigate a response from public institutions that reinforces the messages impact on the target audience). In summary there are two approaches basically to address health problems which are change people’s behavior or change the environment. Barbra and Glanze suggested that the most useful health promotion and behavior change interventions integrate these two approaches and treat them both as essential. Because individual behavior both influences, and influenced by the environment so it is better to design multidimensional and effective health promotion program.

However, Thomas and Lawrence (1978), pointed that the probability of change tend to be a function of how much commitment people have to existing behavior patterns i.e., under high commitment conditions, as is frequently the case in health care, bringing about change may indeed be a difficult undertaking. This is likely to be the case since health behavior is frequently rooted both in long term reinforcement patterns and in support by the individual’s social environment. In some special cases physical and psychological addition patterns may also be a factor with which to struggle against it.

According to Sparks (2010) theory driven and evidence based health communication interventions must be continually evaluated for effectiveness and adjusted accordingly. If such evaluation reveals that certain variables are not receiving the consideration need, then new, better adjusted theoretically-based outreach interventions can be developed in order to achieve health outcomes. Another point to evaluate is the complementary effect of behavioral prediction and communication theories.

2.2.5 Complementary Relationship for maximum result

According to Poon, Choi, & Davis (2007) the concept of Complementarity was first introduced by Edgeworth (1881) in which he defined activities as compliment if doing( more of ) any one of them increases the returns to doing( more of) the other. Therefore, the impact of a system of Complementarity practice will be greater than the sum of its parts because of the synergistic effects of bundling practices together. Poon et al.,(2007) added that if complementarities among activities exist, then the gains from increasing every component are larger than the sum of individual increases. In other words, a test for complementarities must consider performance data on some function that is hypothesized to be super-modular (separate but have synergic effect). It means analysis of complementarities requires us to hypothesize potential components to exhibits a relationship of increased returns.

2.3 Intervention by Communication of the Intervention

According to Fishbein (2008) intervention should address beliefs that are significantly related to the behavior in question. One also went to address beliefs when there are enough people who do not hold the “appropriate” belief. That is, one wants to make sure that the intervention will change the beliefs of a long segment of the target audience. And also one has to address beliefs that are “changeable.” For this one has to craft a convincing message-one supported by reasonable arguments and, if possible, hard data. Fishbein & Ajzen (2005) suggested the intervention can use a number of different strategies (e.g., role-play, interactive questioning, learned mastery experiences) to bring about changes in behavioral, normative and control beliefs, changes that were found to be reflected in intended and actual behaviors. They added their argument that producing favorable intentions is, for certain behaviors for some individuals, not enough to produce a change in the target behavior. In this instance, tow interventions may be required, one to produce the desired intention and another, very different intervention to facilitate performance of the intended behavior. Similarly Fishbein (2000) stated the need for very different intervention for those that formed an intention but is unable to act upon it, than if one has little or no intention to perform the behavior in question. Thus in some populations or cultures, the behavior may not be done because people have not yet formed intentions to perform the behavior; while in others, the problem may be a lack of skills and/or the presence of environmental constraints. In still other cultures, more than one of these factors may be relevant. The problem may be according to Fishbein (2008) is lack of skill or abilities or internal or external barriers preventing them from acting on their intention. The appropriate intervention in this case is the one directed at skill building or helping people overcome or avoid barriers. So as it was indicated in AIDSCAP (2002) cited from Fishbein (1994) that in order to develop appropriate interventions for a specific population and behavior it is important to determine which variable and its corresponding cognitive structures exerts the greatest influence on the study population.

Many researches indicate that interventions change hand washing behavior and underlining constructs. Anne Johanne SOgaad (1988) research result indicated compared to the baseline a significant increase was found in percentage that had correct knowledge of the specific health issues. Similarly in Lopez-Quintero (2009) research indicated a high level of perceived control was the strongest predictor of positive hand-washing intentions (adjusted odds ratio [AOR]=6.0; 95% confidence interval[CI]=4.8,7.5). In another research Wossen (2010) identified that intention was strongly associated with proper hand washing behavior. Nearly one third (33%) of respondents reported positive intentions toward proper hand washing with soap practice.

Different intervention strategies show effective behavioral changes in hand washing. According to Curtis et al., (2001) intervention effect research result shows the use of radio, face-to-face discussions, Booklet developed for children classroom education, workshop organized for partner agencies community leaders, artists and writers are also involved. Fishbein & Ajzen (2005) and McAlister (1991) indicated interpersonal contact together with media, like portable that can be carrier away and consumed later, enable the participants to gather and review performance. The strategic components of Amhara region hygiene and sanitation program HIP (2010) describes behavior change through community level activities like coffee ceremonies, children’s patrols, peer pressure, use of radio message and radio dramas, news stories, and print materials like pamphlets. And also the methods used are taking health education to households, community conversations were employed health extension workers and volunteer community health promoters are used. In the program document regarding the types of intervention mentioned are: school hygiene and sanitation promotion, introduction of hand washing station made from local materials and introduction of local detergents such as ash for soap substitutes.

Certain practices Wijk (1993) suggested, cannot be achieved by individual change alone, but require concerted (i.e., perform together) action from larger groups and whole communities. Sara (2008) mentioned the advantage of helping each other to reach; behavior change will result in strengthening the communal sprit and developing the health of the individual. In addition to this Sara (2008) mentioned the participatory approach can diversify the picture by letting the target group themselves identify their complex nature of determinants and how to approach the problem. Therefore, encouraging hand washing behavior requires a multifaceted approach, working on all the different determinants on the same time and at all levels of society.

2.3.2 Intervention using Multimedia: Community level

In many of the cases studies have tended to be targeted at mothers and female caregivers as they are identified to be the primary caregivers of children less than five years of age (Lisa Danquah, 2010).

The study conducted by Ejemot et al.,(2008) shows intervention activities that employs multiple promotional techniques resulted effective behavioral change on hand washing(like audio and video tapes, pamphlets, practical demonstrations, drama, posters, games, peer monitoring, small group discussions, radio, posters, and pictorial stories etc.). Hyndman (2001) made a research in titled Health Communication and Community Mobilization: Complementary Strategies for Health Promotion, in that by using face to face communication combined with media effectively promoted healthy behaviour and reduced health risk behaviours among low income people in South East Texas. It is called Su Salud Project where issues like prevent cigarette smoking, cancer risk, reduce alcohol abuse, increase physical activities etc. The researcher used two main strategies: the use of media messages through print materials and face-to-face communications by trained community members. In addition to these television programs, news paper articles, discussion at churches & sport groups. The result changes include medical checkups by people, stopping smoking, weight loss and the initiation of exercise groups. In another research in Ghana, Halder et al., (2010) utilized a multi-channel communication hand washing interventions successfully conveyed the message that hands were not truly clean unless washed with soap. In this research they mention that efforts to improve hand washing with soap in Bangladesh will need to directly address the belief on the importance of soap in order to improve hand washing behavior and unlock the potential of such public health intervention. In the case of a cross-sectional study from Kerala, India by Cairncross et al., (2005) to study causes of sustainable changes in hygiene behavior, in addition to other the general mobilization (group meetings, exhibitions, films, and street drama) to create demand and inform the advantage pictorial instruction booklets and pamphlets are distributed to youth and women groups. Which followed by three sessions or “classes” about important topics of health and hygiene, technical skills of latrine construction and maintenance as well as use of them. Wijk et al., (1993) suggested motivating change in hygiene practice like hand washing also mean addressing issues of means, control and power in hygiene practice. So train the participants on the production of their own hygiene equipments such as Tipp Tap, soap handler, and stands etc. Similarly to change low normative beliefs i.e., low expectations regarding hand washing Fenson-Hood (2010) suggests that the intervention must raise peer expectations through peer modeling and train-the-trainer program which results improvement of hand washing behavior. On another research conducted in Karachi, Pakistan by Luby et al., (2005) where 306 households control and 300 with 2 month intervention on hand washing promotion (group participants from 10 to 15 meet for 30-45 minutes where slide shows, video tapes, and pamphlets to illustrate health problems resulting from contaminated hands and give illustrations then they make discussion) including supervision and provision of antibacterial soap as well as plain soap. The result shows children younger than 5 years in households that received plain soap and hand washing promotion had a 50% lower incidence of pneumonia than controls. Also compared to control, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhea and 34% lower incidence of skin disease (impetigo). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap.

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