Social norms, behavior change interventions, and hand hygiene practice in household, school and community settings (Doctoral dissertation).

Low and middle-income countries face a high burden of infectious diseases, especially among young children. Hand hygiene, the act of washing one's hands with water and soap or cleaning the hands with waterless hand cleanser, disrupts pathogen transmission and prevents infectious disease. However, handwashing is infrequently practiced in households, schools and communities due to a number of physical and psychosocial factors. Physical factors include lack of access to water and soap, and difficulty in maintaining bar soap due to theft or loss. Psychosocial factors include low level of disgust, lack to motivation of wash hands, lack of handwashing habit formation, and lack of social norms on handwashing. 

Social norms are defined as informal rules that govern individuals’ behaviors. Social norms consist of two components: the perceived extent to which relevant others engage in the behavior (“empirical expectation”), and the perceived extent to which relevant others think the individual ought to engage in the behavior (“normative expectation”). However, several knowledge gaps remain. Firstly, no previous study has quantitatively measured social norms for handwashing, or assessed the association between social norms and handwashing outcomes. Secondly, there is a knowledge gap with regard to the effect of combined intervention that included a hardware component to improve access to water and soap and a behavior change component that aimed to increase disgust for unwashed hands and increase social norms for handwashing on handwashing outcomes in schools. Lastly, there are few evaluations of large-scale handwashing behavior change field trials that describe the effect of the intervention on handwashing outcomes in community settings. 

To address the above gaps, this dissertation had three specific aims: (1) To assess the association between normative expectation, one of the two components of social norms, and indicators of handwashing in the household; (2) To describe the effect of a social norms-based intervention and soapy water technology on availability of handwashing materials in schools and handwashing behavior among schoolchildren; (3) To describe the effect of a large-scale behavior change intervention on availability of handwashing materials and handwashing behavior in the community.