Public health practitioners increasingly agree that it is not enough to provide people with water and sanitation hardware. Numerous approaches are used to tackle the “software” which means to ensure behavior change necessary to come along with the sanitation hardware. A review of these approaches reveals several shortcomings, most importantly that they do not provide behavioral change interventions which correspond to psychological factors to be changed. This article presents a sound psychological model, which postulates that for the formation of new habitual behavior, five blocks of factors must be positive with regard to the new behavior: risk factors, attitudinal factors, normative factors, ability factors, and self-regulation factors. Standardized tools for measuring the factors in face-to-face interviews are presented, and behavioral interventions are provided for each factor block. A statistical analysis method is presented, which allows the determination of the improvement potential of each factor.

Escherichia coli pathotypes (i.e., enteropathogenic and enterotoxigenic) have been identified among the pathogens most responsible for moderate-to-severe diarrhea in low- and middle-income countries (LMICs). Pathogenic E. coli are transmitted from infected human or animal feces to new susceptible hosts via environmental reservoirs such as hands, water, and soil. Commensal E. coli, which includes nonpathogenic E. coli strains, are widely used as fecal bacteria indicator, with their presence associated with increased likelihood of enteric pathogens and/or diarrheal disease. In this study, we investigated E. coli contamination in environmental reservoirs within households (N = 142) in high-population density communities of Harare, Zimbabwe. We further assessed the interconnectedness of the environmental compartments by investigating associations between, and household-level risk factors for, E. coli contamination. From the data we collected, the source and risk factors for E. coli contamination are not readily apparent. One notable exception is the presence of running tap water on the household plot, which is associated with significantly less E. coli contamination of drinking water, handwashing water, and hands after handwashing. In addition, E. coli levels on hands after washing are significantly associated with handwashing water contamination, hand contamination before washing, and diarrhea incidence. Finally, we observed that animal ownership increases E. coli contamination in soil, and E. coli in soil are correlated with contamination on hands before washing. This study highlights the complexity of E. coli contamination in household environments within LMICs. More, larger, studies are needed to better identify sources and exposure pathways of E. coli—and enteric pathogens generally—to identify effective interventions.

Community-led total sanitation (CLTS) is a widely used, community-based approach to tackle open defecation and its health-related problems. Although CLTS has been shown to be successful in previous studies, little is known about how CLTS works. We used a cross-sectional case study to identify personal, physical, and social context factors and psychosocial determinants from the Risks, Attitudes, Norms, Abilities, and Self-Regulation (RANAS) model of behavior change, which are crucial for latrine ownership and analyze how participation in CLTS is associated with those determinants. Structured interviews were conducted with 640 households in 26 communities, where CLTS had been completed before and compared to 6 control communities, all located in northern Mozambique in 2015. To identify crucial factors for latrine ownership, logistic regression analysis were conducted and mediation analysis were used to analyse the relationship between CLTS participation and latrine ownership mediated by factors identified by the logistic regression analyses. Mediation analysis reveal that the relationship of CLTS participation with probability of owning a latrine is mediated by social context factors and psychosocial determinants. Data analysis reveal that the probability of building a latrine depends on existing social context factors within the village, the behavior of others in the community, the (dis)approval of others of latrine ownership, personal self-confidence in latrine building, and a precise communication of the benefits of latrine ownership during a CLTS triggering event. By including activities to focus on the mentioned factors, CLTS could be improved. Exemplary adaptations are discussed.

Open defecation is connected to poor health and child mortality, but billions of people still do not have access to safe sanitation facilities. Community-Led Total Sanitation (CLTS) promotes latrine construction to eradicate open defecation. However, the mechanisms by which CLTS works and how they can be improved remain unknown. The present study is the first to investigate the psychosocial determinants of CLTS in a longitudinal design. Furthermore, we tested whether CLTS can be made more effective by theory- and evidence-based interventions using the risks, attitudes, norms, abilities, and selfregulation (RANAS) model. A cluster-randomized controlled trial of 3216 households was implemented in rural Ghana. Communities were randomly assigned to classic CLTS, one of three RANAS-based interventions, or to the control arm. Prepost surveys at 6-month follow-up included standardized interviews assessing psychosocial determinants from the RANAS model. Regression analyses and multilevel mediation models were computed to test intervention effects and mechanisms of CLTS. Latrine coverage increased pre-post by 67.6% in all intervention arms and by 7.9% in the control arm (p < .001). The combination with RANAS-based interventions showed non-significantly greater effects than CLTS alone. The effects of CLTS on latrine construction were significantly mediated by changes in four determinants: others' behaviour and approval, self-efficacy, action planning and commitment. Changes in vulnerability, severity, and barrier planning were positively connected to latrine construction but not affected by CLTS. This study corroborates the effectiveness of CLTS in increasing latrine coverage, and additional activities can be improved further. Behaviour change techniques within CLTS that strengthened the relevant factors should be maintained. The study also recommends interventions based on the RANAS approach to improve CLTS. Further research is needed to understand the effects of RANAS-based interventions combined with CLTS at longer follow-up.

In this research project, we studied factors that presumably affect the incidence of diarrhoea among young children in urban slums in developing countries: consumption of safe drinks, hygiene behaviour, cleanliness of household surroundings and the quality of raw water. Beliefs concerning the causes of diarrhoea were also related to health-improving behaviour, namely the application of the water-treatment method SODIS (solar water disinfection) and hygiene behaviour. We conducted a survey in a shanty town in Nairobi, Kenya. Field workers interviewed 500 households. Analysis with regression models revealed that two out of the four postulated factors were significant: children have a lower risk of contracting diarrhoea when they consume high percentages of safe drinks and live in households with good hygiene. As regards beliefs, we found that biomedical knowledge of children's diarrhoea as well as the perceived social norm for treating water was associated with the use of SODIS and good hygiene.

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. 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. 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. 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.