Judith Palfrey, MD, is director of the Global Pediatrics Program in the Department of Medicine at Boston Children’s Hospital.
Diarrhea is a bigger global killer than HIV and malaria combined. It accounts for more than 800,000 deaths each year among children 0-5 years. And how tragic this is when the simple intervention of hand washing can prevent some of these deaths. Results of a trial, published in the March edition of The Lancet Global Health, indicate that teaching families in under-resourced areas of the world about hand washing is not only possible but also scalable, sustainable and successful – if it’s done the right way.
Hand washing is a simple intervention, but the prevalence of the behavior is as low as 1 to 2 percent in some under-resourced global settings. A London School of Hygiene and Tropical Medicine group, led by Adam Biran, PhD, decided to try to improve these statistics by devising an effective intervention.
However, the route to simple solutions is often complex. The researchers used very sophisticated methodology to identify the levers of behavioral change. They realized that health messages about hand washing have not worked. The idea that what I do today may prevent diarrhea down the road just did not have enough oomph to motivate people to adopt a new routine.
The researchers hypothesized that emotional drivers (including nurture, status, disgust and belonging) would be strong pushes to get families to wash their hands. And they were right.
So, how did the group achieve the positive health-related outcome of good hand hygiene using non-health-oriented methodology? They employed best practices in social motivation and marketing and turned to media consultants and event planners. Their multi-faceted intervention involved championing by village leaders, school programming, public pledges by parents and colorful badges for children.
The campaign featured a video, posters and other materials starring an attractive, articulate woman named SuperAmma and a comedic, disorderly, dirty male character as a foil. The contrast between the two characters was captivating, motivating and effective. Parents wanted to nurture their children the way SuperAmma did. Children were disgusted by the squalid, nasty behaviors of the man who did not clean his hands after defecating. Adults viewed hand washing as a status symbol, and they wanted very much to belong in that community.
The campaign made the right choice the easy choice and promoted the healthy behavior as the norm by drawing on the villagers’ emotions rather than on their cognitive reasoning.
The SuperAmma campaign increased hand washing from 1 percent at baseline to 19 percent at six weeks and 37 percent at the six-month follow-up. These results indicate that once the behavior took hold in the communities it was sustained.
The success of this campaign points to the value of simple interventions and also shows the underlying complexity involved in achieving elegant results. In the global context, there are many opportunities for simple interventions of this type to address the challenges that continue to claim the lives of 6 million children under the age of 5 each year.
Other simple global health interventions – like a minimally invasive and relatively inexpensive operation for hydrocephalus that avoids the need for shunts, infant warmers and bubble c-pap for newborns, and the Helping Babies Breathe program – also have produced dramatic outcomes in low-resource settings.
These examples, along with the findings of Biran and his colleagues, could set the stage for additional simple interventions, including hand washing in clinical settings, breast feeding enhancement, provision of nutritional supplements to starving children, distribution of bed nets to prevent malaria and other mosquito-borne illnesses, provision of insulin for children with diabetes and anti-convulsant medications for children with seizures and dissemination of pneumococcal vaccine for children with sickle-cell disease.
