Rice farmers' knowledge, attitudes and practices towards mosquitoes in irrigation schemes in Côte d'Ivoire: a qualitative study.

BACKGROUND: Irrigated rice cultivation in sub-Saharan Africa not only brings more malaria vectors to nearby communities, but also greater malaria risk. To aid the implementation of mosquito control in rice-growing communities, it is necessary to understand how farmers understand, view and manage their responsibility in mosquito generation and whether they are interested in coordinating to minimize it. METHODS: Qualitative methods (observation grids, semi-structured in-depth interviews and focus group discussions) were used to reveal the perceptions of mosquitoes and their control in two irrigated rice farming communities in central Côte d'Ivoire near the M'bé and Lokapli irrigation schemes. RESULTS: All rice farmers viewed mosquitoes as severe nuisances, and most acknowledged that they caused djèkouadjo (malaria) and were less numerous during harmattan (dry season). Many study participants believed that mosquitoes originated from grasses and stagnant water around villages. Only those living closer in proximity (~ 1 km) to the paddies believed that mosquitoes came from the bas-fonds (irrigated lowlands). However, they did not associate mosquito production with rice cultivation. Some farmers believed that there were more mosquitoes in recent years than historically because of the dam construction, but remarked on the importance of the dam (and bas-fonds) for their livelihood. Many farmers were not convinced that mosquito control could occur at farm-level. CONCLUSIONS: To enhance accountability amongst rice farmers, there is a need for greater awareness on the rice-mosquito link, and emphasis that the link does not imply a trade-off between food production and health. Training should not only be directed towards farming communities, but also agricultural and health extension workers. Future riceland mosquito control methods must focus on improving crop productivity and address collective action problems that may occur.

What works in sanitation promotion?

Promotion appears to be the least effective but is nevertheless often the only available, means to achieve increased access to sanitation services, especially at scale, in lower-income countries. A cursory examination of the history of past and present approaches to sanitation promotion, including sanitation marketing, community development, community-led total sanitation and public health, shows that they have a variety of features and characteristics which make them distinctive. Unfortunately, rigorous evaluation has not kept pace with this proliferation of approaches, so it is difficult to recommend any one approach over the others, based on empirical performance in a range of circumstances. However, I argue that a 'hybrid' approach which exhibits a number of salient features from all of the previous approaches is likely to be a good bet. I present a recent example of such a hybrid programme which proved to significantly increase the rate of improved sanitation coverage through promotion (without subsidy of any kind) at scale in Tanzania. I suggest other sanitation promotion programs may want to think about adopting similar practices in their own programming going forward.

Lessons from a successful national sanitation programme: the case of Nyumba ni Choo in Tanzania.

Universal access to hygienic sanitation is a Sustainable Development Goal for international development. However, many countries are liable to miss this target by the deadline of 2030. As provision and subsidy are prohibitively expensive, promotion is the tactic commonly taken by governments and stakeholders in many countries, even though it is often not effective at generating significant changes in sanitation coverage. A recent 5-year programme used an international consortium made up of organizations' experts in consumer research, creative communication, programme management and event implementation, media monitoring and programme evaluation, to achieve significant increases in the coverage of improved sanitation facilities throughout Tanzania, using adaptive programming. A number of lessons, outlined here, can be drawn from this experience which are likely to be applicable to promotion efforts in other countries and contexts and which can hopefully help countries to reach their sanitation targets. These lessons include the use of motivation and targeted expertise rather than reliance on training, the use of the theory of change to guide development processes, targeting of high-level government support, collaboration with private sector actors, testing and refreshing of messaging, continuous monitoring of on-ground conditions, use of multiple modes of outreach and branding of all programme outputs.

Intervention design in public health: adaptive messaging in the Tanzanian National Sanitation Campaign.

Few case studies exist in the public health or design literatures showing how to create national scale messaging campaigns in low-income countries using design processes. In this paper, we describe how we used Behaviour Centred Design to develop Nyumba ni choo, the Tanzanian National Sanitation Campaign. The process involved multiple iterations of ideation and filtration by professional creatives, government staff, academics and sanitation specialists to create a branded mass communication campaign, which was refreshed annually. The campaign was based on the insight that Tanzania is modernizing rapidly, with people upgrading their homes, but leaving their outside toilets in a 'traditional' state. Built around the 'big idea' that a household is not fully modern without a good-quality, modern toilet, the campaign employed reality TV shows, live engagements and mass and digital media postings, all targeted at motivating both the government and general population to improve toilets. The campaign has made toilets a topic of national conversation and has led to a major uptick in the rate of toilet building. Efforts to improve public health-related behaviour can be enhanced by using systematic approaches that build on available evidence, understand behaviour in its common settings, employ psychological theory and engage creative expertise.

Cluster-randomised trial to test the effect of a behaviour change intervention on toilet use in rural India: results and methodological considerations.

BACKGROUND: Effective and scalable behaviour change interventions to increase use of existing toilets in low income settings are under debate. We tested the effect of a novel intervention, the '5 Star Toilet' campaign, on toilet use among households owning a toilet in a rural setting in the Indian state of Gujarat. METHODS: The intervention included innovative and digitally enabled campaign components delivered over 2 days, promoting the upgrading of existing toilets to achieve use by all household members. The intervention was tested in a cluster randomised trial in 94 villages (47 intervention and 47 control). The primary outcome was the proportion of households with use of toilets by all household members, measured through self- or proxy-reported toilet use. We applied a separate questionnaire tool that masked open defecation questions as a physical activity study, and excluded households surveyed at baseline from the post-intervention survey. We calculated prevalence differences using linear regression with generalised estimating equations. RESULTS: The primary study outcome was assessed in 2483 households (1275 intervention and 1208 control). Exposure to the intervention was low. Post-intervention, toilet use was 83.8% in the control and 90.0% in the intervention arm (unadjusted difference + 6.3%, 95%CI 1.1, 11.4, adjusted difference + 5.0%, 95%CI -0.1, 10.1. The physical activity questionnaire was done in 4736 individuals (2483 intervention and 2253 control), and found no evidence for an effect (toilet use 80.7% vs 82.2%, difference + 1.7%, 95%CI -3.2, 6.7). In the intervention arm, toilet use measured with the main questionnaire was higher in those exposed to the campaign compared to the unexposed (+ 7.0%, 95%CI 2.2%, 11.7%), while there was no difference when measured with the physical activity questionnaire (+ 0.9%, 95%CI -3.7%, 5.5%). Process evaluation suggested that insufficient campaign intensity may have contributed to the low impact of the intervention. CONCLUSION: The study highlights the challenge in achieving high intervention intensity in settings where the proportion of the total population that are potential beneficiaries is small. Responder bias may be minimised by masking open defecation questions as a physical activity study. Over-reporting of toilet use may be further reduced by avoiding repeated surveys in the same households. TRIAL REGISTRATION: The trial was registered on the RIDIE registry ( RIDIE-STUDY-ID-5b8568ac80c30 , 27-8-2018) and retrospectively on clinicaltrials.gov ( NCT04526171 , 30-8-2020).

Using a theory-driven creative process to design a peri-urban on-site sanitation quality improvement intervention.

BACKGROUND: Behavior change interventions have been developed by drawing from many different theories using design processes of varying specificity. We describe the development of a behavior change intervention to improve on-site peri-urban sanitation quality in Lusaka, Zambia using the Behavior Centered Design (BCD) framework to explain the results of the process applied to improving the quality of shared peri-urban sanitation and compare them to similar interventions. METHODS: We used the BCD behavioral determinants model to synthesize the data from our literature review and formative research. Then, we partnered with creative professionals using a design process to develop a theory-driven on-site peri-urban sanitation intervention. Particular attention was paid to the implications of using BCD for intervention development on improving its effectiveness, increasing the contributions to knowledge for other behaviors and settings, and advancing the discipline of applied behavioral science. RESULTS: Based on findings from a literature review and formative research, we designed an intervention to encourage landlords to improve their toilets by making them more accessible, desirable, hygienic, and sustainable. The intervention involved landlords meeting in facilitated groups every 2 weeks with individual follow-up after each meeting. The meetings presented surprising "hidden camera"-style videos to reveal tenants' perspectives, used participatory activities to help landlords reevaluate the benefits they would derive from improving sanitation on their plots, and provided practical guidance and mechanisms to facilitate the performance of construction and cleaning behaviors. CONCLUSIONS: Using the BCD framework provided an easy-to-follow intervention design process. The resulting intervention is highly creative and multi-faceted, with each element having a theoretical role in an explicit theory of change. The development of this theory-driven intervention advances applied behavioral science by facilitating evaluation of each of the behavior change techniques and the overall delivery mechanism hypothesized to change the target behaviors. This informs the adaptation of these findings to improving on-site sanitation in other settings and the iterative development of the BCD model, which can be used to more effectively change other behaviors.

Theory-driven formative research on on-site, shared sanitation quality improvement among landlords and tenants in peri-urban Lusaka, Zambia.

Rapid, unplanned urbanization in low-income countries is leading to increasing problems of dealing with human waste. On-site sanitation systems are often rudimentary, unhygienic, and poorly maintained. In-depth, on-site interactive interviews were conducted with 33 landlords and 33 tenants in a neighborhood in peri-urban Lusaka to understand on-site, shared sanitation quality improvement behaviors and preferences. Respondents were asked about housing characteristics, toilet histories, and financial decision-making. Improved, shared toilets were common (79%), but many were of low quality and poorly cleaned. Poor coordination among tenants, barriers to communication between landlords and tenants, and landlords viewing sanitation as a required basic service to provide instead of something for which tenants will pay more rent all limit the quality of sanitation in this setting. Landlord-directed interventions targeting non-health motivations for sanitation improvement and introducing effective cleaning systems may increase peri-urban sanitation quality.

Implementing effective hygiene promotion: lessons from the process evaluation of an intervention to promote handwashing with soap in rural India.

BACKGROUND: An intervention trial of the 'SuperAmma' village-level intervention to promote handwashing with soap (HWWS) in rural India demonstrated substantial increases in HWWS amongst the target population. We carried out a process evaluation to assess the implementation of the intervention and the evidence that it had changed the perceived benefits and social norms associated with HWWS. The evaluation also aimed to inform the design of a streamlined shorter intervention and estimate scale up costs. METHODS: Intervention implementation was observed in 7 villages. Semi-structured interviews were conducted with the implementation team, village leaders and representatives of the target population. A questionnaire survey was administered in 174 households in intervention villages and 171 households in control villages to assess exposure to intervention activities, recall of intervention components and evidence that the intervention had produced changes in perceptions that were consistent with the intervention core messages. Costs were estimated for the intervention as delivered, as well as for a hypothetical scale-up to 1,000 villages. RESULTS: We found that the intervention was largely acceptable to the target population, maintained high fidelity (after some starting problems), and resulted in a high level of exposure to most components. There was a high recall of most intervention activities. Subjects in the intervention villages were more likely than those in control villages to cite reasons for HWWS that were in line with intervention messaging and to believe that HWWS was a social norm. There were no major differences between socio-economic and caste groups in exposure to intervention activities. Reducing the intervention from 4 to 2 contact days, in a scale up scenario, cut the estimated implementation cost from $2,293 to $1,097 per village. CONCLUSIONS: The SuperAmma intervention is capable of achieving good reach across men and women of varied social and economic status, is affordable, and has the potential to be effective at scale, provided that sufficient attention is given to ensuring the quality of intervention delivery.

Unintentional behaviour change.

We argue that the authors ignore a broad range of possible means of changing behaviour: unintentional change. Most of the behaviours that people seek to change - either in themselves or that are the subject of public health campaigns-are habitual, and hence not necessarily responsive to intentions. An evolutionary approach should take into account all kinds of evolved behavioural responses.

Applying the Barker School concept of 'behaviour settings' to virtual contexts.

People are spending more and more time interacting with virtual objects and environments. We argue that Roger Barker's concept of a 'behaviour setting' can be usefully applied to such experiences with relatively little modification if we recognize subjective aspects of such experiences such as presence and immersion. We define virtual behaviour settings as virtual environments where the partly or fully digital milieu is synomorphic with and circumjacent to embodied behaviour, as opposed to the fragmented behaviour settings of much-mediated interaction. We present two tools that can help explain and predict the outcomes of virtual experiences-the behaviour setting canvas (BSC) and model-and demonstrate their utility through examples. We conclude that the behaviour setting concept is helpful in both designing virtual environments and understanding their impact, while virtual environments offer a powerful new methodological paradigm for studying behaviour settings. This article is part of the theme issue 'People, places, things, and communities: expanding behaviour settings theory in the twenty-first century'.

Experimenting to increase the effectiveness of a national campaign on hygiene behavior in Tanzania.

Through Tanzania's National Sanitation Campaign, we study the effectiveness of two common elements of behavior change campaigns: endorsements from celebrities and testimonials. Using four experiments in Tanzania in early 2021 as part of the national campaign, we find that including endorsements and testimonials in text messages sent to individuals significantly increases self-reported hygiene behavior. These results mask important heterogeneity based on the source of endorsement or framing of the testimonial and provide insights into cost-effective approaches for changing behavior at scale.

The context and practice of handwashing among new mothers in Serang, Indonesia: a formative research study.

BACKGROUND: This article reports on formative research into the context and practice of handwashing with soap by new mothers, which can substantially impact child morbidity and mortality. New mothers are an important target group for handwashing interventions: they are considered particularly susceptible to behaviour change and their actions can directly affect a child's health. METHODS: Twenty-seven mothers of infants (including neonates) from urban and rural sub-districts of Serang were recruited and filmed over a period of eight hours. Video footage was used to identify handwashing occasions and to understand the context in which behaviour took place. Each woman was subsequently interviewed. RESULTS: Handwashing with soap was found to be infrequent, typically occurring after eating, cooking and household chores or after cleaning a child's bottom. Handwashing before preparing food or eating was rare. Pre-pregnancy routines were reported to have been disrupted. Advice on child care comes from many sources, particularly the midwife and new child's grandmother. CONCLUSIONS: Developing interventions to change perceptions and practice of handwashing would seed an important behaviour and could save lives. New mothers represent an ideal target group for such an intervention. We suggest that interventions target an increase in handwashing with soap after contact with own and a baby's faecal matter as part of the post-defecation hygiene routines. As the child's grandmother is an authoritative source of information about parenting, interventions focussed on improving newborn care could target grandmothers as well as midwives.

Process Evaluation of an Acute-Care Nurse-Centred Hand Hygiene Intervention in US Hospitals.

This paper describes a process evaluation of a 'wise' intervention that took place in six acute care units in two medical-surgical teaching hospitals in the United States during 2016-2017. 'Wise' interventions are short, inexpensive interventions that depend on triggering specific psychological mechanisms to achieve behaviour change. This study sought to increase the hand hygiene compliance (HHC) rates before entering a patient's room among nurses. The intervention centred on the use of threat to professional identity to prompt improved HHC. Through questionnaires administered to intervention participants and the implementation facilitator, together with independent observation of intervention delivery, we examined whether the steps in the Theory of Change occurred as expected. We found that aspects of the implementation-including mode of delivery, use of incentives, and how nurses were recruited and complied with the intervention-affected reach and likely effectiveness. While components of the intervention's mechanisms of impact-such as the element of surprise-were successful, they ultimately did not translate into performance of the target behaviour. Performance was also not affected by use of an implementation intention as repeated performance of HHC over years of being a nurse has likely already established well-ingrained practices. Context did have an effect; the safety culture of the units, the involvement of the Nurse Managers, the level of accountability for HHC in each unit, and the hospitals themselves all influenced levels of engagement. These conclusions should have implications for those interested in the applicability of 'wise' interventions and those seeking to improve HHC in hospitals.

Testing the human superorganism approach to morality.

Current theories in moral psychology do not agree about the kinds and range of offenses that people should moralize. In this study, a new approach to defining the moral domain, Human Superorganism Theory (HSoT), is presented and tested. HSoT proposes that the primary function of moral action is the suppression of cheaters in the unusually large societies recently established by our species (i.e., human 'superorganisms'). It suggests that a broad range of moral concerns exist beyond traditional notions of harm and fairness, including actions that inhibit functions such as group-level social control, physical and social structuring, reproduction, communication, signaling and memory. Roughly 80,000 respondents completed a web-based experiment hosted by the British Broadcasting Corporation, which elicited a suite of responses to characteristics of a set of 33 short scenarios representing the areas identified by the HSoT perspective. Results indicate that all 13 superorganism functions are moralized, while violations of scenarios falling outside this area (social customs and individual decisions) are not. Several hypotheses derived specifically from HSoT were also supported. Given this evidence, we believe this new approach to defining a broader moral domain has implications for fields ranging from psychology to legal theory.

The Impact of On-Ground Activation Events on Improved Toilet Coverage: A Case Study From the Tanzania National Sanitation Campaign "Nyumba ni Choo".

In 2017, Tanzania was one of the countries in the world with the lowest proportion of households having access to improved toilets. Between 2017 and 2021, the government launched a national sanitation campaign under the brand Nyumba ni Choo. The objective of this paper is to assess the impact of one component of this campaign, "direct consumer contact" events, on the coverage of improved household latrines in Tanzania. Secondary data from both the National Sanitation Management Information System (NSMIS; https://nsmis.moh.go.tz/) and internal project reports were used to extract data on coverage and dates of events, respectively. Regression estimation models were used to estimate impact at ward and regional levels. The study used quarterly panel data from all 26 regions between 2017 (baseline) and 2020 (endline) for estimation purposes. The study shows that direct consumer contact events had a significant positive effect on the rate at which households subsequently improved their toilets at both small and large scale in Tanzania. On average, the rate of household latrine improvement increased by 12.91% at ward level and 14.17% at regional level. These results testify to the importance of designing an effective behavioral change campaign to achieve significant improvements in sanitation coverage.

Development of a novel hand cleansing product for low-income contexts: The case of tab soap.

Handwashing with soap is a widely advocated public health measure, but seldom practiced, partly because it is often difficult (especially outside of rich Western country contexts) to make both soap and water readily available in relevant situations. This study used both Behaviour Centred Design and Human Centred Design to guide development of a novel hand cleansing technology appropriate for the context of post-toilet hand cleansing in resource-poor societies. Extensive prototyping and field testing resulted in the pilot production of 'tab' soap, a small but durable single-use, decomposable substrate embedded with soap. It can be produced in dispenser roll or tear-off formats. With this affordable solution, one may use soap without worrying about contamination pretty much anytime and anywhere. A small-scale field test showed that all poor households in rural and peri-urban areas in Tanzania included in the proof-of-concept study (N = 12 households) would use the product reliably over the medium term. Tab soap awaits full-scale production and marketing but could make hand cleansing a more popular practice around the world.

The evolution of the human healthcare system and implications for understanding our responses to COVID-19.

The COVID-19 pandemic has revealed an urgent need for a comprehensive, multidisciplinary understanding of how healthcare systems respond successfully to infectious pathogens-and how they fail. This study contributes a novel perspective that focuses on the selective pressures that shape healthcare systems over evolutionary time. We use a comparative approach to trace the evolution of care-giving and disease control behaviours across species and then map their integration into the contemporary human healthcare system. Self-care and pro-health environmental modification are ubiquitous across animals, while derived behaviours like care for kin, for strangers, and group-level organizational responses have evolved via different selection pressures. We then apply this framework to our behavioural responses to COVID-19 and demonstrate that three types of conflicts are occurring: (1) conflicting selection pressures on individuals, (2) evolutionary mismatches between the context in which our healthcare behaviours evolved and our globalized world of today and (3) evolutionary displacements in which older forms of care are currently dispensed through more derived forms. We discuss the significance of understanding how healthcare systems evolve and change for thinking about the role of healthcare systems in society during and after the time of COVID-19-and for us as a species as we continue to face selection from infectious diseases.

Development of a behaviour change intervention using a theory-based approach, Behaviour Centred Design, to increase nurses' hand hygiene compliance in the US hospitals.

BACKGROUND: A behaviour change campaign is unlikely to be effective if its intervention is not carefully designed. While numerous frameworks are widely used to develop and evaluate interventions, the steps detailing how to create an intervention are not as clear because the process of linking behaviour analysis to the intervention design is seldom discussed. We document the application of the Behaviour Centred Design (BCD) approach to the development of an intervention to improve hand hygiene (HH) rates among nurses' hospital units in the USA. METHODS: Intervention development is divided into the first three steps of the BCD approach: Assess, Build, and Create. The Assess step centres on understanding the target behaviour. The Build step expands the knowledge of the target behaviour and population through formative research which leads to a creative brief that explains the focus of the intervention. In the Create step, the creative brief guides the intervention design. RESULTS: Drawing from the main findings of the Asses and Build steps, a focal insight was developed positing that nurses can rediscover the meaning and purpose of their role as a nurse and thus as a caregiver by practicing HH; in the process of cleaning their hands, nurses are living up to their ideal nurse-self. The focal insight was linked linguistically into a theory and change. The outcome was a simple intervention, called the Mainspring Intervention, which consisted of three major parts: a self-affirmation exercise to reduce defensiveness, a message that challenged nurses' perceptions about their HH practice, and an implementation intention activity to help nurses link HH behaviour to a cue. CONCLUSIONS: We detailed the creation of an original HH intervention that used the BCD approach. The intervention is relatively simple compared to most HH initiatives in the literature, both in terms of having relatively few components to the intervention and relatively easy field implementation. This intervention will allow us to test how specific psychological processes contribute to the problem of low HH rates, how our proposed intervention changes these processes in the hospital setting, and how the expected change in nurses' cognition transforms over time because of the intervention.

Psychometric Analysis of a Postulated Set of Evolved Human Motives.

Many different general systems of human motives have been postulated in the psychological literature. However, as yet, no consensus on which motives should be nominated, nor how many there are, has emerged. Recently, we deduced the existence of a number of motives using a logical argument derived from evolutionary theory; that humans have evolved an independent psychological "engine" to respond to each kind of evolutionary problem set by a dimension of the human niche, or life-way. Here, we confirm the existence of 14 out of 15 of these postulated motives using factor analysis on a web-based sample of 500 respondents from the UK: Lust, Hunger, Fear, Disgust, Attract, Love, Nurture, Hoard, Create, Affiliate, Status, Justice, Curiosity, and Play. The items which loaded most strongly for each factor confirmed the expected core value of each motive. Comfort did not emerge, perhaps because it is more about satisfying specific physiological requirements than a cluster of activities linked semantically by the concept of attaining "comfort." We believe this analysis can form the foundation of a scale for use in applied psychological work ranging from personality testing to personnel selection to public health program design.

Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study.

Hand hygiene is the simplest and most effective measure for preventing healthcare-associated infections. Despite the simplicity of this procedure and advances made in infection control, hospital health care workers' compliance to hand hygiene recommendations is generally low. Nurses have the most frequent patient care interactions, and thus more opportunities to practice hand hygiene. As such, it is important to identify and understand determinants of nurses' reported compliance. Formative research was undertaken to assess the potential impact of several unexamined factors that could influence HH among nurses: professional role and status, social affiliation, social norms, and physical modifications to the work environment (as well as institutional factors like safety climate). A survey questionnaire was developed primarily to inform the creation of a behaviour change intervention. The survey looked at how these factors influence HH among nurses and sought to identify barriers and levers to reported hand hygiene. It was administered to a survey panel of acute care nurses, working in US hospitals, with a year or more of experience. Multivariate regression modelling suggested that reported hand hygiene compliance was most likely to be a function of a hospital management's communication openness, perceived performance by peers, increased interactions with patients and other staff members, and the reduction in stress, busyness, and cognitive load associated with role performance. A powerful, effective intervention on HH among nurses therefore could be directed at improving communication openness, consider the impact of perceived performance by peers, increase interactions with patients and staff, and determine how to reduce the stress and cognitive load associated with role performance.