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Behavioral Insights WASH

The decision to wash hands could be partly related simply to wash basins

The decision to wash hands before food might be simple but of a huge importance across the world and India. We conducted a pilot field study to glean hand washing behavior.

Micro case

By Devang Agarwal

Inputs from Prof. David Levine, Dr. Payel C. Mukherjee, Ouroz Khan, Dr. Sumitava Mukherjee

Introduction

[1] According to a UNICEF report from 2021, 2.3 billion people worldwide are unable to wash their hands with soap and water at home, and one-third of the world’s health facilities lack hand hygiene resources at the point of care. Meanwhile, 817 million children are affected by the lack of basic hygiene services in nearly half of the world’s schools. Interventions to promote hand hygiene should be designed with an understanding of what people care about in mind, and relevant social norms should be used to trigger and reinforce handwashing practice. It is critical to consider motives and emotions that will change people’s long-term mindsets in order to achieve sustained hand hygiene improvements. [2] A study conducted in Indonesia highlights the importance of understanding the behavioral patterns of populations and the socio-economic triggers that affect hand hygiene behaviour in order to effectively use behavior change techniques such as RANAS to design interventions to establish hand hygiene behavior as a social norm for every Indonesian. Keller et al. [3] conducted a pre-post analysis of hand washing and related cognitions (i.e., intention, self-efficacy, and self-monitoring) up to 100 days after intervention and found that hand washing and self-monitoring increased significantly in the weeks following the intervention and self-monitoring was a consistent positive correlate of hand washing. India is a densely populated country with diversity in socio-cultural practices and habits that drive the everyday behavior of populations. Food-borne diseases are common. On one side it is important that the appropriate infrastructure should be provided by the government and private bodies in public places for maintaining hand hygiene, one cannot rule out the importance of behavioral insights on actual on-site eating outlets along with interventions and nudges that could help remind people to maintain proper hand hygiene in public places.

Keeping this in mind, a pilot study was performed at 3 public restaurants within a campus in New Delhi to understand the motivations and habits of individuals and groups eating at these places. The study helped narrow down a few important hygiene indicators that were observed to affect hand hygiene practices – particularly the decision to wash hands, with a future aim to use these indicators as a basis for designing behavioral interventions to facilitate hand hygiene.

Methodology

  1. Rapid Observations

Need for rapid observations – In this methodology of ‘rapid observation,’ the idea was to assimilate the maximum data possible by visiting eateries and restaurants in order to build a clear notion of different aspects related to hand washing. I observed various restaurants inside and outside of a campus in New Delhi to get an overall understanding of the infrastructural facilities available – including the location of the hand washing station, visibility, and the accessibility of the hand washing station from the seating and food ordering area, availability of soap at the hand washing station and sanitizer in the restaurant. Additionally to get a general sense of what kind of food is served – whether it is packaged food or requires direct touching with hand for consumption. 

  1. Ethnographic Observations to establish Hygiene Indicators

We performed ethnographic observations on 3 restaurants to observe the hand hygiene practices of the people dining in these restaurants through the summers of 2022. The shortlisting was done to maintain diversity in some of the hygiene indicators that could affect hand hygiene behavior at eating outlets. Refer Table 1 for details on the factors considered for restaurant characteristics and features. Out of a 100 customers observed during this course, only 2 washed hands before eating at Restaurant 1. 18% of people washed hands with soap at restaurant 2 and a strikingly high 65% people washed hands with soap at restaurant 3. This goes to show the importance of a few hygiene indicators that impact hand hygiene maintenance by individuals and groups. 

One is the visibility and accessibility of the hand washing station. If the hand washing station itself is not visible from the eating area or the food ordering area, people would not remember or be reminded of washing hands before eating. 

Second is the proximity of the hand washing station to the toilet. Presence of a toilet next to a hand washing station might be distracting people from deciding to go ahead with washing their hands as one would be skeptical to use such a hand washing facility that is just adjacent to a toilet. 

Thirdly, at restaurant 1, the hand washing station did not have soap. It is more likely to be unsure of hand hygiene even after washing hands with soap (though it was absent here) due to the presence of a toilet next to it and the usage of the soap by people who access the toilet. 

Table 1 – Restaurant Characteristics

Visibility of Hand washing stationPresence of toilet near hand washing stationSoap PresentGeneral Infrastructure
Restaurant 1Invisible from the eating and food ordering area.Present next to the toilet.NoSingle wash basin which was dirty.
Restaurant 2Partially visible from the eating area. Invisible from the food ordering area.Present next to the toilet.Yes. Liquid Soap3 wash basins present side by side.
Restaurant 3Clearly visible hand washing station present at the entrance of the restaurant.No toilet inside the restaurant.Yes. Liquid SoapIn total 7 wash basins present in an enclosure.

Total people observedLunch/Dinner TimeSnacks Time
Restaurant 1100+Only 2% washed hands with water only.0% washed hands
Restaurant 214618% washed hands with soap and water. 5% washed hands with water only.5% washed hands with soap and water. 2% washed hands with water only.
Restaurant 36565% washed hands with soap and water. 15% washed hands with water only.Restaurant does not serve snacks

Discussion

It seems that few things are at play here while we ethnographically observe hand hygiene behavior amongst people at this restaurant. 

One is that people are a creature of habit and routine and monotony. They are in their own world, walking into the restaurant perhaps chatting with a friend or family member accompanying them, or on the phone with their loved one, or just thinking about other important aspects of their life while they enter the restaurant, move from the entrance up to the food ordering area, look at the menu, decide upon something to eat after much deliberation; all this while performing a multitude of cognitively draining activities all at once. Amidst all this cognitive turmoil, it’s easy to be a part of an automatic routine and forget about hand hygiene. 

We must not forget the person is hungry as well. Skrynka et al. [4] showed that people do not make rational, well-thought-over decisions while hungry. In fact, decision-making gets more present-focused and people’s preferences shift dramatically from the long to short term when hungry. In other words, people become impatient and need instant gratification. They are more likely to settle for a small reward (hunger drives the urge to order food immediately) now than wait for a bigger reward in the future (wait and look around for the hand washing station to ensure individual and public health in the longer term). Hand hygiene isn’t perhaps something that is there on the top of the mind of people walking into dining at any restaurant. Walking into a restaurant, if the hand washing station isn’t something that one notices easily, they wouldn’t want to expend cognitive resources to ask around for the hand washing station when they are hungry and are thinking majorly to satisfy their hunger i.e., in need of instant gratification, they are more likely to forget about hand hygiene. 

Second is the perception of hygiene of a wash basin in common usage with a toilet. Even for individuals who are aware of washing their hands before eating, the presence of a toilet next to the wash basin serves as a demotivating factor since they would be unsure of clean hands even after washing hands from a tap used for cleaning hands after the toilet. 

References

[1] United Nations Children’s Fund and World Health Organization, State of the World’s Hand Hygiene: A global call to action to make hand hygiene a priority in policy and practice, UNICEF, New York, 2021.

[2] Ministry of Health, Republic of Indonesia and UNICEF (2021). Behaviour change interventions for strengthening Handwashing with Soap in Indonesia: A training guide for facilitators and practitioners. UNICEF Indonesia. Jakarta, 2021.

[3] Jan Keller, Dominika Kwasnicka, Lea O. Wilhelm, Noemi Lorbeer, Theresa Pauly, Antonia Domke, Nina Knoll, Lena Fleig “Hand Washing and Related Cognitions Following a Brief behaviour Change Intervention During the COVID-19 Pandemic: a Pre-Post Analysis”

[4] Skrynka, J., Vincent, B.T. Hunger increases delay discounting of food and non-food rewards. Psychon Bull Rev 26, 1729–1737 (2019). https://doi.org/10.3758/s13423-019-01655-0


In collaboration with Dr. David Levine, HAAS School of Business, University of California Berkeley

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