Absorbent hygiene products disposal behaviour in informal settlements: identifying determinants and underlying mechanisms in Durban, South Africa.

BACKGROUND: Within South Africa, many low-income communities lack reliable waste management services. Within these contexts, absorbent hygiene product (AHP) waste, including nappies (diapers), are not recycled, and are often dumped, ending up in watercourses and polluting the local environment. The structural barriers to collection which have been well explored, however the behavioural determinants of safe disposal for AHPs remains poorly understood. The purpose of this study is to determine the psycho-social factors driving AHP disposal behaviour for caregivers, while identifying potential underlying mechanisms (such as mental health), which may be influencing disposal behaviour, with the intention of informing a future, contextually appropriate and sustainable, collection system. METHODS: The cross-sectional study was conducted within three low-income communities located within eThekwini Municipality (Durban), South Africa. The study included a pre-study and a quantitative survey of 452 caregivers, utilising the RANAS approach of behaviour change. The quantitative questionnaire was based on the RANAS model to measure psycho-social factors underlying sanitary disposal of AHPs. Mental health was assessed using the Self-Reporting Questionnaire (SRQ-20). Statistical analysis involved regressing psycho-social factors onto disposal behaviour and exploring their interaction with mental health through a moderation model. RESULTS: Our findings suggest that one third of caregivers do not dispose of nappies sanitarily, despite intent (86.9%). Regression analysis revealed ten psycho-social factors which significantly predict the desired behavioural outcome, the sanitary disposal of AHPs. Caregivers with poor mental health were less likely to dispose of AHP sanitarily, which reflects previous research linking poor mental health and the impairment of health-related daily activities, particularly within vulnerable groups. Specifically, several psycho-social factors underlying were moderated by poor mental health, the prevalence of sanitary disposal of AHPs depended on mental condition of caregiver. CONCLUSIONS: Our findings confirmed the link between poor mental health and unsanitary AHPs disposal. This is especially relevant because poor mental health is common within South Africa. Addressing mental health problems within these communities is an essential step to providing sustainable waste management services. The findings informed an intervention strategy to implement a future collection system for these communities, and similar low-income or informal contexts within South Africa.

Psychosocial factors associated with intention to pursue tertiary education among Malawian students: the moderating effect of mental health.

BACKGROUND: In Sub Saharan Africa (SSA), approximately 9 million students are enrolled in tertiary education (TE), which is 4% of the total TE enrolment globally. Barriers to higher education in SSA are numerous: poverty, food insecurity, gender, and disability, while the COVID-19 pandemic has worsened the situation. Little is known about the psychosocial factors and underlying mechanisms associated with students' intention to apply for TE. Using a psychological theory of behaviour change, our study investigated the psychosocial and context factors associated with the application to TE. METHODS: In a cross-sectional research study 821 interviews using researcher-administered questionnaires were conducted with secondary school students in rural and urban Blantyre, Malawi. A quantitative questionnaire based on the risks, attitudes, norms, abilities, and self-regulation (RANAS) model was used to assess psychosocial factors underlying application for TE. The Centre for Epidemiological Studies Depression Scale for Children (CES-DC) and household hunger scale were used to assess mental health and hunger respectively. RESULTS: More than half of the youth were at risk to develop depression (66.5%). Girls reported experiencing more depression symptoms than boys. Around 1 in every 5 interviewed youth lived in a home experiencing moderate or severe hunger. A higher intention to apply for TE was related to perceived vulnerability, affective beliefs (joy, happiness, excitement), injunctive (approval of others) and personal norms, self-efficacy, and commitment to apply. Factual knowledge about TE application was very limited. An intention to apply for TE and self-efficacy was positively associated with regular physical exercise, but negatively associated with mental health and hunger. However, mental health moderated the effects of physical exercise on the intention to apply for TE. We found significant differences between poor and good mental health groups on intention to apply for TE in perceived vulnerability, descriptive (behaviour of others) and personal norms, self-efficacy, maintenance self-efficacy and commitment factors. The results informed a behaviour change intervention strategy to increase students' intention to apply for TE. CONCLUSIONS: Our research findings are an important contribution to the long-term strategy of achieving the Sustainable Development Goals (SDGs) and contribute to the inclusion of vulnerable students with impaired mental health in higher education in Malawi and beyond.

Does Poor Mental Health Impair the Effectiveness of Complementary Food Hygiene Behavior Change Intervention in Rural Malawi?

Mental disorders have the potential to affect an individual's capacity to perform household daily activities such as water, sanitation, and hygiene (food hygiene inclusive) that require effort, time, and strong internal motivation. However, there is limited detailed assessment about the influence of mental health on food hygiene behaviors at household level. We conducted a follow-up study to detect the effects of mental health on food hygiene behaviors after food hygiene intervention delivery to child caregivers in rural Malawi. Face-to-face interviews, based on the Risk, Attitude, Norms, Ability, and Self-regulations (RANAS) model, were conducted with 819 participants (control and intervention group) to assess their handwashing and food hygiene-related behaviors. Mental health was assessed using the validated Self-Reporting Questionnaire. Study results showed a significant negative relationship between mental health and handwashing with soap behavior (r = -0.135) and keeping utensils in an elevated place (r = -0.093). Further, a significant difference was found between people with good versus poor mental health on handwashing with soap behavior (p = 0.050) among the intervention group. The results showed that the influence of the intervention on handwashing with soap behavior was mediated by mental health. Thus, integration of mental health in food hygiene interventions can result in improved outcomes for caregivers with poor mental health.

Improving Complementary Food Hygiene Behaviors Using the Risk, Attitude, Norms, Ability, and Self-Regulation Approach in Rural Malawi.

The study evaluated the effectiveness of an intervention to improve complementary food hygiene behaviors among child caregivers in rural Malawi. Formative research and intervention development was grounded in the risk, attitude, norms, ability, and self-regulation (RANAS) model and targeted washing hands and kitchen utensils with soap, safe utensil storage, reheating of leftover food, and feeding of children by caregivers. Longitudinal research was applied at baseline and follow-up surveys among 320 caregivers. Determinants of selected behaviors were found, and interventions were developed based on the behavior change techniques aligned with these determinants in the RANAS model. The intervention was delivered over 9 months through group (cluster) meetings and household visits and included demonstrations, games, rewards, and songs. We randomly assigned villages to the control or intervention group. Follow-up results indicated a significant increase in three targeted behaviors (washing kitchen utensils with soap, safe utensil storage, and handwashing with soap) among intervention recipients. Several psychosocial factors differed significantly between the intervention and control groups. Mediation results showed that the intervention had a significant effect on these three targeted behaviors. For handwashing, feelings, others' behavior in the household, and remembering; for washing kitchen utensils, others' behavior in the household and difficulty to get enough soap; for safe utensils storage, others' behavior in the village and remembering mediated the effect of the intervention on the targeted behaviors. The study demonstrated that targeting food hygiene behaviors with a theory-driven behavior change approach using psychosocial factors can improve the behavior of child caregivers in rural Malawi.

The link between mental health and safe drinking water behaviors in a vulnerable population in rural Malawi.

BACKGROUND: Mental disorders, particularly depression and post-traumatic stress disorder, are common long-term psychological outcomes in emergency contexts arising from conflicts, natural disasters, and other challenging environmental conditions. In emergencies, people suffer not only from the lack of external resources such as drinking water and food but also from poor mental health. Mental disorders can substantially impair daily activities in vulnerable individuals. However, water, sanitation, and hygiene (WASH) behaviors are daily activities that require effort, time, and strong internal motivation. Therefore, questions arise: whether there is a relationship between mental health and safe water behaviors, and if so, whether the motivational drivers of these behaviors are affected by mental health. METHODS: Our cross-sectional study conducted face-to-face interviews with 638 households in rural Malawi. We used a quantitative questionnaire based on the risks, attitudes, norms, abilities, and self-regulation (RANAS) approach to measure motivational psychosocial factors. Mental health was assessed using the validated Chichewa version of the Self-Reporting Questionnaire (SRQ-20). RESULTS: Almost a third of the respondents reported poor mental health. We found significant negative association between mental health and self-reported safe water collection (p = .01, r = -.104) but not between safe water transportation and storage behavior. The moderation analysis revealed significant interaction effects of mental health with some psychosocial factors and therefore on WASH behaviors. Poor mental health changed the influence of three psychosocial factors-perceived others' behavior, commitment, and remembering-on safe drinking water collection behavior. The influence on water transportation and storage behavior of the perceived severity of contracting a disease, the belief that transporting and storing water requires substantial effort, and others' approval depended on the mental health condition of the respondent. CONCLUSIONS: These results imply that populations with a significant proportion of individuals with poor mental health will benefit from interventions to mitigate mental health before or parallel to behavioral change interventions for WASH. Specific population-level interventions have been shown to have a positive effect on mental well-being, and they have been successfully applied at scale. This research is especially relevant in emergency contexts, as it indicates that mental health measures before any WASH interventions will make them more effective.

The Impact of Various Promotional Activities on Ebola Prevention Behaviors and Psychosocial Factors Predicting Ebola Prevention Behaviors in the Gambia Evaluation of Ebola Prevention Promotions.

The outbreak of the Ebola virus disease (EVD) from 2014 to 2016 is over. However, several outbreaks of contagious diseases have already arisen and will recur. This paper aims to evaluate the effectiveness of EVD prevention promotions in the Gambia and to assess the psychosocial factors that steer three behaviors: handwashing with soap, calling the Ebola Hotline, and not touching a person who might be suffering from EVD. In 2015, data were gathered from 498 primary care providers. The questionnaire was based on psychosocial factors from the risks, attitudes, norms, abilities, and self-regulation (RANAS) model. Three promotional activities were significantly associated with psychosocial factors of handwashing and, thus, with increased handwashing behavior: the home visit, posters, and info sheets. Norm factors, especially the perception of what other people do, had a great impact on handwashing with soap and on calling the Ebola Hotline. The perceived certainty that a behavior will prevent a disease was a predictor for all three protection behaviors. Commitment to the behavior emerged as especially relevant for the intention to call the Ebola Hotline and for not touching a person who might be suffering from EVD. Health behavior change programs should rely on evidence to target the right psychosocial factors and to maximize their effects on prevention behaviors, especially in emergency contexts.

Toward Complementary Food Hygiene Practices among Child Caregivers in Rural Malawi.

Despite being preventable, foodborne diseases remain a global health challenge. Poor food hygiene practices such as improper handling of kitchen utensils are among the major causes of diarrhea transmission. A formative study was conducted in Malawi to inform an intervention design to promote complementary food hygiene practices. An assessment of contextual and psychosocial factors for behavior change was conducted using Risk, Attitude, Norms, Ability, and Self-regulation model. We conducted 323 household surveys with caregivers of children aged 6 to 24 months. Analysis of variance was used to estimate difference between doers and non-doers of three targeted behaviors: washing utensils with soap, keeping utensils on a raised place, and handwashing with soap. Analysis of variance analyses revealed that literacy level, ownership of animals, and presence of handwashing facility and dish racks were contextual factors predicting storage of utensils on an elevated place and handwashing frequencies. Psychosocial factors, such as time spent to wash utensils with soap, distance to the handwashing facility, and cost for soap, had an influence on washing utensils and handwashing practices. Perceived vulnerability determined effective handwashing and storage of utensils. Perceived social norms and ability estimates were favorable for the three targeted behaviors. Promotion of already existing targeted beneficial behaviors should be encouraged among caregivers. Risk perceptions on storage of utensils and handwashing practices should be increased with motivational exercises such as paint games. Caregivers' technical know-how of local dish rack and tippy tap construction is essential.

Characterizing the Last Latrine Nonowners in Rural Malawi.

Open defecation is a public health problem worldwide. Non-governmental organizations in developing countries use various approaches to increase latrine coverage, but for little-understood reasons, some of the population does not adopt latrine construction. The objective of our research was to uncover which of the factors predicting latrine construction are relevant to the last nonowners of latrines, termed laggards in the diffusion of innovations theory. In a cross-sectional study, quantitative face-to-face interviews were conducted in households in rural Malawi (N = 824) to assess the behavioral determinants of latrine construction, mental health, and leadership. Around 14% of the households interviewed did not own a latrine. Study results suggest that nonowners have limited economic resources and perceive that latrine construction is expensive, that it is difficult to find money for latrine construction, and that it needs a lot of time and effort. The last nonowners of latrines live in smaller groups than latrine owners, communicate less with others about latrine construction, and are less influenced by the opinion of their leaders. They consist, in particular, of socially vulnerable households, are younger, are less educated, often have more impaired mental health, feel more vulnerable to contracting diseases, are less aware of the latrine construction of others in the village, feel less personally obliged to construct their own latrines, and are less confident in their ability to rebuild latrines damaged by flooding. The study confirmed that the assumptions of the diffusion of innovation theory are useful in combination with the risks, attitudes, norms, abilities, and self-regulation behavior change approach for developing evidence-based behavior change strategies in developing countries.

Does depression moderate handwashing in children?

BACKGROUND: Although diarrheal diseases are preventable and treatable, they are the leading cause of child mortality and morbidity as a consequence of poor hygiene and contaminated water. Handwashing with soap is an effective method for preventing and decreasing the incidence of diarrhea. However, mental disorders such as depression can substantially moderate an individual's ability to cope with daily life and can exert a negative influence on daily hygiene activities such as handwashing with soap, especially in children. The aim of this study was to explain the influence of depression on pupils' hand-washing behavior in Zimbabwe. METHODS: In a cross-sectional study, face-to-face interviews were carried out with primary school pupils in peri-urban Harare, Zimbabwe (n = 556) using a quantitative questionnaire to assess handwashing and its behavioral determinants in school settings. The Center for Epidemiological Studies Depression Scale for Children (CES-DC) was used to assess depression. RESULTS: More than half of the assessed children were depressed. Self-reported handwashing with soap among depressed children was significantly lower than among non-depressed children. Almost all behavioral determinants of hand-washing behavior were significantly lower in depressed children. The behavioral determinants worked differently in the depressed children than in the non-depressed children's group. The effects of important behavioral determinants on handwashing were moderated by depression. CONCLUSIONS: Depression exerts a negative influence on handwashing in children. These results suggest depression-relieving measures should be conducted together with any water, sanitation, and hygiene (WASH) interventions to make such interventions more effective.

Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe.

BACKGROUND: This article presents the development of a school handwashing programme in two different sub-Saharan countries that applies the RANAS (risk, attitudes, norms, ability, and self-regulation) systematic approach to behaviour change. METHODS: Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. Regression analyses were used to assess the influence of the RANAS behavioural determinants on reported handwashing frequencies. RESULTS: The results revealed that, in both countries, a programme targeting social norms and self-efficacy would be most effective. In Burundi, raising the children's perceived severity of the consequences of contracting diarrhoea, and in Zimbabwe, increasing the children's health knowledge should be part of the programme. CONCLUSIONS: The school handwashing programme should create awareness of the benefits of handwashing through educational activities, raise the children's ability and confidence in washing hands at school through infrastructural improvements, and highlight the normality of washing hands at school through events and poster creation.

Contextual and psychosocial factors predicting Ebola prevention behaviours using the RANAS approach to behaviour change in Guinea-Bissau.

BACKGROUND: The outbreak of the Ebola virus disease (EVD) in West Africa in December 2013 was the largest Ebola outbreak in history. This study aimed to measure the underlying contextual and psychosocial factors of intentions to perform Ebola prevention behaviours (not touching people who might be suffering from Ebola, reporting suspected cases to the National Ebola Hotline, NEH) in Guinea-Bissau. Geographical location, cross-border market activities, poor water, sanitation and hygiene (WASH) conditions, and burial practices in some communities pose a serious risk in terms of potential EVD outbreak and seriously hamper its prevention in Guinea-Bissau. METHODS: In July and August 2015, quantitative data from 1369 respondents were gathered by structured face-to-face interviews. The questionnaire was based on the psychosocial factors of the RANAS (risks, attitudes, norms, abilities, and self-regulation) model. Data were analyzed by multiple linear regression analyses. RESULTS: The most important predictors for the intention to call the NEH were believing that calling the Hotline would help the infected person, perceiving that important members from the household approve of calling the Hotline, thinking that calling the Hotline is something they should do, and believing that it is important to call the Hotline to report a suspected case. For the intention not to touch someone who might be suffering from Ebola, the most important predictors were health knowledge, the perception of risk with regard to touching a person who might be suffering from Ebola, and the belief that they were able not to touch a possibly infected person. Age in years was the only significant contextual predictor for one of the two behavioural intentions, the intention to call the Hotline. It seems that younger people are more likely to use a service like the NEH than older people. CONCLUSIONS: Strengths and gaps were identified in the study population in relation to the intention to perform prevention behaviours. These call for innovative ways of aligning existing hygiene programs with relevant psychosocial factors. This research is relevant to further outbreaks of contagious diseases as it sheds light on important aspects of the impact of public health interventions during emergencies and epidemics.