The Effects of Integrative Behavioral Prediction and Media Priming on the Hand Washing Behavior of Primary School Children

A study in North Gondar Zone

Master's Thesis, 2011

128 Pages, Grade: Very Good



Title Page

Approval page


Table of contents

List of tables

List of figures

List of abbrevations/acronyms


1.1Background of the Study
1.2 Statement of the problem
1.3 Objective of the study
1.4 Significance of the Study
1.5 Delimitation and Limitations of the Study
1.6 Definition of Terms

2.1 Hand Washing as Hygiene Tool
2.1.1 Magnitiude of Diarrhea and Hygiene Related Risks
2.1.2 Behaviour Risk Factors
2.1.3 Critical Time for Hand Washing
2.1.4 Hand Washing Practice
2.2.5 Impact of Hand Washing
2.2 Theoretical Frameworks
2.2.1 Theory of Reasoned Action (TRA)
2.2.2 Theory of Planned Behaviour (TPB)
2.2.3 Integrative Behavioural Prediction (IBP)
2.2.4 Communication for Behaviour Change Communication Strategies Communication and Attitudnal Change Health Communication Principles
2.2.5 Complementarity Theory
2.3 Intervention by Comminication
2.3.1 Appropraiteness of the Intervention
2.3.2 Intervention Using Multimedia Community Level
2.3.3 Intervention using Multimedia School level
2.4 Conceptual Frame Work
2.5 Summary of the Litratures

3.1 Research design
3.2 Study Area
3.3 Participants of the Study
3.4 Sampling procedure and sample size
3.5 Variables
3.6 Instrumentation and Measures
3.7 Data Collaction
3.8 Identification of beliefs for Intervention
3.9 Experimental Manipulation or Intervention
3.10 Effectiveness of the intervention
3.11 Validity and Reliability
3.12 Ethical Considerations
3.13 Data Analysis Method

4.1 Results of Descriptive data

5.1 Summary
5.2 Conclusion
5.3 Recommendation


Appendix 1: Informed consent
Appendix 2: Questionnaire
Appendix 3: Amharic translation and of all data collection instruments
Appendix 4: Hand washing interpretation and score making Larson & Lusk, 1985) second model
Appendix 5: On spot house observation checklist
Appendix 6: Elicitation questions
Appendix 7: The verse of hand washing song that developed by the researcher and utilized for... communication of hand washing message
Appendix 8: Pictures of How to wash hand with soap and critical moments (USAID)


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.


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

Table 5: Summary of ANOVA for the prediction of pre intervention intention

Table 6: Regression analysis for prediction of pre intervention Intention

Table 7: Multiple Regression analysis for the prediction of Intention

Table 8: Wilcoxon test result of knowledge change

Table 9: Wilcoxon test result 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



Figure 1: The F-Diagram

Figure 2: Integrated Behavior Model

Figure 3: Conceptual Framework

Figure 4: Summary of Descriptive Statistics Pre and Post intervention


illustration not visible in this excerpt


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 complementary 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.


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.

Does beliefs that important reference persons or groups expect hand washing with water and soap has any influence on student’s perceived injective norm?

Dose beliefs that important reference persons or groups perform hand washing with water and soap has any influence on students perceived descriptive norm?

What is the strongest predictor of student’s intention to wash their hand with water and soap?

Does student’s positive experiential and instrumental attitude towards hand washing with water and soap have any influence intention to practice it?

Is their positive relationship between student’s perceived control and intention to wash their hand by water with soap?

Does student’s knowledge and practical skill of hand washing with water and soap have any influence on their behavior change?

Does student’s exposure (participation and exposure to communication) on hand washing behavior have any influence on their hand washing behavior change?

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


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.


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)


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. (p.3)

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 illustration not visible in this excerpt 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)


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The Effects of Integrative Behavioral Prediction and Media Priming on the Hand Washing Behavior of Primary School Children
A study in North Gondar Zone
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complimentary, effects, integrative, behavioral, prediction, media, priming, message, delivery, changing, hand, washing, behavior, primary, school, children, chandba, north, gondar, zone
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Getnet Eshetu (Author), 2011, The Effects of Integrative Behavioral Prediction and Media Priming on the Hand Washing Behavior of Primary School Children, Munich, GRIN Verlag,


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