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CHAPTER ONE
INTRODUCTION
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 death
in Ethiopia 23% due to diarrhea, where under five mortality rate 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 born 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
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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
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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
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poor. Regarding hand washing facilities hygiene and sanitation survey sponsored by Save the
Children Norway-Ethiopia was recently conducted survey. This servey 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 hand, 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 Behavioural Prediction (Fishbein & Yzer, 2003)
will constitute the principal theory, by means of which the determinants of hand washing related
behaviour 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 behavioural research.
Fishbein & Yzer (2003) introduced the Integrative Model of Behavioural 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).
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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
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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 provison 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 formuleted.
1. Does beliefs that important reference persons or groups expect hand washing with water
and soap has any influence on student’s perceived injective norm?
2. Dose beliefs that important reference persons or groups perform hand washing with water
and soap has any influence on students perceived descriptive norm?
3. What is the strongest predictor of student’s intention to wash their hand with water and
soap?
4. Does student’s positive experiential and instrumental attitude towards hand washing with
water and soap have any influence intention to practice it?
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5. Is their positive relationship between student’s perceived control and intention to wash
their hand by water with soap?
6. Does student’s knowledge and practical skill of hand washing with water and soap have
any influence on their behavior change?
7. Does student’s exposure (participation and exposure to communication) on hand washing
behavior have any influence on their hand washing behavior change?
8. Does student’s intention towards hand washing with water and soap have any influence
on hand washing behavior?
9. 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.
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1.5 Delimitation and Limitations
Delimitation
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.
Limitation
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
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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)
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