Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Public Health
Published in: BMC Public Health 1/2013

Open Access 01-12-2013 | Research article

The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings

Authors: Robert Dreibelbis, Peter J Winch, Elli Leontsini, Kristyna RS Hulland, Pavani K Ram, Leanne Unicomb, Stephen P Luby

Published in: BMC Public Health | Issue 1/2013

Login to get access

Abstract

Background

Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance.

Methods

We completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH).

Results

We identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models under-represented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual).

Conclusions

A number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices.
Appendix
Available only for authorised users
Literature
1.
EHP, UNICEF/WES, USAID, World Bank/WSP, WSSCC: The Hygiene Improvement Framework: A Comprehensive Approach for Preventing Childhood Diarrhea. 2004, Washington, DC: Environmental Health Project, 29-
2.
Peal A, Evans B, van der Voorden C: Hygiene and Santiation Software: An Overview of Approaches. In. 2010, Geneva, Switzerland: Water Supply & Sanitation Collaborative Council
3.
Watt J: The Tippy Tap: a simple handwashing device for rural areas. J Trop Pediatr. 1988, 34 (2): 91-92. 10.1093/tropej/34.2.91.CrossRefPubMed
4.
Clasen T, Schmidt WP, Rabie T, Roberts I, Cairncross S: Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. BMJ. 2007, 334 (7597): 782-10.1136/bmj.39118.489931.BE.CrossRefPubMedPubMedCentral
5.
Arnold B, Colford J: Treating water with chlorine at point-of-use to improve water quality and reduce child diarrhea in developing countries: A systematic review and meta-analysis. Am J Trop Med Hyg. 2007, 76 (2): 354-364.PubMed
6.
Clasen TF, Bostoen K, Schmidt WP, Boisson S, Fung IC, Jenkins MW, Scott B, Sugden S, Cairncross S: Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database Syst Rev. 2010, CD007180-6
7.
Howitt P, Darzi A, Yang GZ, Ashrafian H, Atun R, Barlow J, Blakemore A, Bull AM, Car J, Conteh L, et al: Technologies for global health. Lancet. 2012, 380 (9840): 507-535. 10.1016/S0140-6736(12)61127-1.CrossRefPubMed
8.
Chiller TM, Mendoza CE, Lopez MB, Alvarez M, Hoekstra RM, Keswick BH, Luby SP: Reducing diarrhoea in Guatemalan children: randomized controlled trial of flocculant-disinfectant for drinking-water. Bull World Health Organ. 2006, 84 (1): 28-35.CrossRefPubMedPubMedCentral
9.
Khan MU: Interruption of shigellosis by hand washing. Trans R Soc Trop Med Hyg. 1982, 76 (2): 164-168. 10.1016/0035-9203(82)90266-8.CrossRefPubMed
10.
Quick RE, Venczel LV, Mintz ED, Soleto L, Aparicio J, Gironaz M, Hutwagner L, Greene K, Bopp C, Maloney K, et al: Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiol Infect. 1999, 122 (1): 83-90. 10.1017/S0950268898001782.CrossRefPubMedPubMedCentral
11.
Stanton BF, Clemens JD: An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in urban Bangladesh. II. A randomized trial to assess the impact of the intervention on hygienic behaviors and rates of diarrhea. Am J Epidemiol. 1987, 125 (2): 292-301.PubMed
12.
Rotondo LA, Ngondi J, Rodgers AF, King JD, Kamissoko Y, Amadou A, Jip N, Cromwell EA, Emerson PM: Evaluation of community intervention with pit latrines for trachoma control in Ghana, Mali, Niger and Nigeria. Int Health. 2009, 1 (2): 154-162. 10.1016/j.inhe.2009.08.001.CrossRefPubMed
13.
Curtis V, Kanki B, Cousens S, Diallo I, Kpozehouen A, Sangaré M, Nikiema M: Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bull World Health Organ. 2001, 79 (6): 518-527.PubMedPubMedCentral
14.
Luby SP, Mendoza C, Keswick BH, Chiller TM, Hoekstra RM: Difficulties in bringing point-of-use water treatment to scale in rural Guatemala. Am J Trop Med Hyg. 2008, 78 (3): 382-387.PubMed
15.
Parker AA, Stephenson R, Riley PL, Ombeki S, Komolleh C, Sibley L, Quick R: Sustained high levels of stored drinking water treatment and retention of hand-washing knowledge in rural Kenyan households following a clinic-based intervention. Epidemiol Infect. 2006, 134 (5): 1029-1036. 10.1017/S0950268806005954.CrossRefPubMedPubMedCentral
16.
Luby SP, Aeboatwalla M, Bowen A, Kenah E, Sharker Y, Hoekstra RM: Difficulties in maintaining improved handwashing behavior, Karachi, Pakistan. Am J Trop Med Hyg. 2009, 81 (1): 140-145.PubMed
17.
Ammerman AS, Lindquist CH, Lohr KN, Hersey J: The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Prev Med. 2002, 35 (1): 25-41. 10.1006/pmed.2002.1028.CrossRefPubMed
18.
Baker HJ, Butler LT, Chambers SA, Traill WB, Lobb AE, Herbert G: An RCT study to evaluate a targeted, theory driven healthy eating leaflet. Soc Sci Med. 2010, 71 (11): 1916-1920. 10.1016/j.socscimed.2010.09.023.CrossRefPubMed
19.
Glanz K, Bishop DB: The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 2010, 31: 399-418. 10.1146/annurev.publhealth.012809.103604.CrossRefPubMed
20.
Morrow GR, Bellg AJ: Behavioral science in translational research and cancer control. Cancer. 1994, 74 (4 Suppl): 1409-1417.CrossRefPubMed
21.
Noar SM, Benac CN, Harris MS: Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull. 2007, 133 (4): 673-693.CrossRefPubMed
22.
Parker Fiebelkorn A, Person B, Quick RE, Vindigni SM, Jhung M, Bowen A, Riley PL: Systematic review of behavior change research on point-of-use water treatment interventions in countries categorized as low- to medium-development on the human development index. Soc Sci Med. 2012, 75 (4): 622-633. 10.1016/j.socscimed.2012.02.011.CrossRef
23.
Hulland KR, Leontsini E, Dreibelbis R, Unicomb L, Afroz A, Dutta NC, Nizame FA, Luby SP, Ram PK, Winch PJ: Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC Public Health. 2013, 13 (1): 877-10.1186/1471-2458-13-877.CrossRefPubMedPubMedCentral
24.
Hanson JA, Benedict JA: Use of the Health Belief Model to examine older adults' food-handling behaviors. J Nutr Educ Behav. 2002, 34 (Suppl 1): S25-S30.CrossRefPubMed
25.
O'Boyle CA, Henly SJ, Larson E: Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001, 29 (6): 352-360. 10.1067/mic.2001.18405.CrossRefPubMed
26.
Anstiss RG, Ahmed M: A conceptual model to be used for community-based drinking-water improvements. J Health Popul Nutr. 2006, 24 (3): 262-266.PubMedPubMedCentral
27.
Hurlimann A, Dolnicar S, Meyer P: Understanding behaviour to inform water supply management in developed nations–a review of literature, conceptual model and research agenda. J Environ Manage. 2009, 91 (1): 47-56. 10.1016/j.jenvman.2009.07.014.CrossRefPubMed
28.
Rainey RC, Harding AK: Acceptability of solar disinfection of drinking water treatment in Kathmandu Valley, Nepal. Int J Environ Health Res. 2005, 15 (5): 361-372. 10.1080/09603120500289168.CrossRefPubMed
29.
Carpenter CJ: A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Commun. 2010, 25 (8): 661-669. 10.1080/10410236.2010.521906.CrossRefPubMed
30.
Janz NK, Becker MH: The Health Belief Model: a decade later. Health Educ Q. 1984, 11 (1): 1-47. 10.1177/109019818401100101.CrossRefPubMed
31.
Wood S, Foster J, Kols A: Understanding why women adopt and sustain home water treatment: insights from the Malawi antenatal care program. Soc Sci Med. 2012, 75 (4): 634-642. 10.1016/j.socscimed.2011.09.018.CrossRefPubMed
32.
Jenkins MW, Scott B: Behavioral indicators of household decision-making and demand for sanitation and potential gains from social marketing in Ghana. Soc Sci Med. 2007, 64 (12): 2427-2442. 10.1016/j.socscimed.2007.03.010.CrossRefPubMed
33.
Prochaska JO, DiClemente CC, Norcross JC: In search of how people change. Applications to addictive behaviors. Am Psychol. 1992, 47 (9): 1102-1114.CrossRefPubMed
34.
Curtis VA, Danquah LO, Aunger RV: Planned, motivated and habitual hygiene behaviour: an eleven country review. Health Educ Res. 2009, 24 (4): 655-673. 10.1093/her/cyp002.CrossRefPubMedPubMedCentral
35.
Curtis V, Schmidt W, Luby S, Florez R, Touré O, Biran A: Hygiene: new hopes, new horizons. Lancet Infect Dis. 2011, 11 (4): 312-321. 10.1016/S1473-3099(10)70224-3.CrossRefPubMed
36.
Mosler HJ: A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. Int J Environ Health Res. 2012, 22 (5): 431-449. 10.1080/09603123.2011.650156.CrossRefPubMed
37.
Figueroa ME, Kincaid DL: Social, Cultural, and Behavioral Correlates of Household Water Treatment and Storage. Center Publication HCI 2010-1: Health Communication Insights. 2010, Baltimore: Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs
38.
Coombes Y, Devine J: Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs. 2010, Washington DC: The World Bank, Water and Sanitation Program: Working Paper, 22-
39.
Devine J: Introducing SaniFOAM: A Framework to Analyze Sanitation Behaviors to Design Effective Sanitation Programs. 2009, Washington DC: The World Bank, Water and Sanitation Program. Working Paper, 22-
40.
McLeroy KR, Bibeau D, Steckler A, Glanz K: An ecological perspective on health promotion programs. Health Educ Q. 1988, 15 (4): 351-377. 10.1177/109019818801500401.CrossRefPubMed
41.
Sweat MD, Denison JA: Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS. 1995, 9 (Suppl A): S251-S257.PubMed
42.
Golden SD, Earp JA: Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education & Behavior Health Promotion Interventions. Health Educ Behav. 2012, 39 (3): 364-372. 10.1177/1090198111418634.CrossRefPubMed
43.
Rimal R, Lapinski M, Turner M, Smith K: The attribute-centered approach for understanding health behaviors: Initial ideas and future research directions. Stud Commun Sci. 2011, 11 (1): 15-34.
44.
Verplanken B: Beyond frequency: habit as mental construct. Br J Soc Psychol. 2006, 45 (Pt 3): 639-656.CrossRefPubMed
45.
46.
Garriga RG, Foguet AP: Unravelling the Linkages Between Water, Sanitation, Hygiene and Rural Poverty: The WASH Poverty Index. Water Resour Manag. 2013, 27 (5): 1501-1515. 10.1007/s11269-012-0251-6.CrossRef
47.
Schmidt WP, Aunger R, Coombes Y, Maina PM, Matiko CN, Biran A, Curtis V: Determinants of handwashing practices in Kenya: the role of media exposure, poverty and infrastructure. Trop Med Int Health. 2009, 14 (12): 1534-1541. 10.1111/j.1365-3156.2009.02404.x.CrossRefPubMed
48.
Cifuentes E, Alamo U, Kendall T, Brunkard J, Scrimshaw S: Rapid assessment procedures in environmental sanitation research: a case study from the northern border of Mexico. Can J Public Health. 2006, 97 (1): 24-28.PubMed
49.
Becker MH, Maiman LA, Kirscht JP, Haefner DP, Drachman RH: The Health Belief Model and prediction of dietary compliance: a field experiment. J Health Soc Behav. 1977, 18 (4): 348-366. 10.2307/2955344.CrossRefPubMed
50.
Fishbein M, Ajzen I: Belief, attitude, intention, and behavior: An introduction to theory and research. 1975, Reading, MA: Addison-Wesley
51.
Ajzen I: The theory of planned behavior. Organ Behav Hum Decis Process. 1991, 50: 179-211. 10.1016/0749-5978(91)90020-T.CrossRef
52.
Aunger R, Schmidt WP, Ranpura A, Coombes Y, Maina PM, Matiko CN, Curtis V: Three kinds of psychological determinants for hand-washing behaviour in Kenya. Soc Sci Med. 2010, 70 (3): 383-391. 10.1016/j.socscimed.2009.10.038.CrossRefPubMed
53.
Curtis V: Hygiene: how myths, monsters, and mothers-in-law can promote behaviour change. J Infect. 2001, 43 (1): 75-79.CrossRefPubMed
54.
Curtis V: Talking dirty: how to save a million lives. Int J Environ Health Res. 2003, 13 (Suppl 1): S73-S79.CrossRefPubMed
55.
Kar K, Chambers R: Handbook on community-led total sanitation. 2008, London, UK, Plan UK: Brighton, UK, Institute of Development Studies at the University of Sussex
56.
Pattanayak SK, Yang JC, Dickinson KL, Poulos C, Patil SR, Mallick RK, Blitstein JL, Praharaj P: Shame or subsidy revisited: social mobilization for sanitation in Orissa, India. Bull World Health Organ. 2009, 87 (8): 580-587. 10.2471/BLT.08.057422.CrossRefPubMedPubMedCentral
57.
Porzig-Drummond R, Stevenson R, Case T, Oaten M: Can the emotion of disgust be harnessed to promote hand hygiene? Experimental and field-based tests. Soc Sci Med. 2009, 68 (6): 1006-1012. 10.1016/j.socscimed.2009.01.013.CrossRefPubMed
58.
Judah G, Aunger R, Schmidt WP, Michie S, Granger S, Curtis V: Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health. 2009, 99 (SUPPL 2): S405-S411.CrossRefPubMedPubMedCentral
59.
Jenkins MW, Curtis V: Achieving the 'good life': why some people want latrines in rural Benin. Soc Sci Med. 2005, 61 (11): 2446-2459. 10.1016/j.socscimed.2005.04.036.CrossRefPubMed
60.
Rogers EM: Diffusion of innovations. 2003, New York: Free Press, 5
61.
Waterkeyn J, Cairncross S: Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe. Soc Sci Med. 2005, 61 (9): 1958-1970. 10.1016/j.socscimed.2005.04.012.CrossRefPubMed
62.
Scott B, Curtis V, Rabie T, Garbrah-Aidoo N: Health in our hands, but not in our heads: understanding hygiene motivation in Ghana. Health Policy Plan. 2007, 22 (4): 225-233. 10.1093/heapol/czm016.CrossRefPubMed
63.
Rosen L, Zucker D, Brody D, Engelhard D, Manor O: The effect of a handwashing intervention on preschool educator beliefs, attitudes, knowledge and self-efficacy. Health Educ Res. 2009, 24 (4): 686-698. 10.1093/her/cyp004.CrossRefPubMed
64.
Mosler HJ, Blochliger OR, Inauen J: Personal, social, and situational factors influencing the consumption of drinking water from arsenic-safe deep tubewells in Bangladesh. J Environ Manage. 2010, 91 (6): 1316-1323. 10.1016/j.jenvman.2010.02.012.CrossRefPubMed
65.
Luby SP, Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston RB: Household characteristics associated with handwashing with soap in rural Bangladesh. Am J Trop Med Hyg. 2009, 81 (5): 882-887. 10.4269/ajtmh.2009.09-0031.CrossRefPubMed
66.
67.
Devine J: Beyond tippy-taps: The role of enabling products in scaling up and sustaining handwashing. Waterlines. 2010, 29 (4): 304-10.3362/1756-3488.2010.033.CrossRef
68.
Arvai J, Post K: Risk Management in a Developing Country Context: Improving Decisions About Point-of-Use Water Treatment Among the Rural Poor in Africa. Risk Analysis. 2012, 32 (1): 67-80. 10.1111/j.1539-6924.2011.01675.x.CrossRefPubMed
69.
Katukiza AY, Ronteltap M, Oleja A, Niwagaba CB, Kansiime F, Lens PNL: Selection of sustainable sanitation technologies for urban slums, A case of Bwaise III in Kampala, Uganda. Sci Total Environ. 2010, 409 (1): 52-62. 10.1016/j.scitotenv.2010.09.032.CrossRefPubMed
70.
Crosby R, Noar SM: Theory development in health promotion: are we there yet?. J Behav Med. 2010, 33 (4): 259-263. 10.1007/s10865-010-9260-1.CrossRefPubMed
71.
Sultana R, Mondal UK, Rimi NA, Unicomb L, Winch PJ, Nahar N, Luby SP: An improved tool for household faeces management in rural Bangladeshi communities. Trop Med Int Health. 2013, 18 (7): 854-860. 10.1111/tmi.12103.CrossRefPubMed
72.
Sweat M, Kerrigan D, Moreno L, Rosario S, Gomez B, Jerez H, Weiss E, Barrington C: Cost-effectiveness of environmental-structural communication interventions for HIV prevention in the female sex industry in the Dominican Republic. J Health Commun. 2006, 11 (Suppl 2): 123-142.CrossRefPubMed
73.
Biran A, Rabie T, Schmidt W, Juvekar S, Hirve S, Curtis V: Comparing the performance of indicators of hand-washing practices in rural Indian households. Trop Med Int Health. 2008, 13 (2): 278-285. 10.1111/j.1365-3156.2007.02001.x.CrossRefPubMed
74.
Stevenson RJ, Case TI, Hodgson D, Porzig-Drummond R, Barouei J, Oaten MJ: A scale for measuring hygiene behavior: development, reliability and validity. Am J Infect Control. 2009, 37 (7): 557-564. 10.1016/j.ajic.2009.01.003.CrossRefPubMed
75.
Vindigni SM, Riley PL, Jhung M: Systematic review: handwashing behaviour in low- to middle-income countries: outcome measures and behaviour maintenance. Trop Med Int Health. 2011, 16 (4): 466-477. 10.1111/j.1365-3156.2010.02720.x.CrossRefPubMed
76.
Inauen J, Hossain MM, Johnston RB, Mosler H-J: Acceptance and Use of Eight Arsenic-Safe Drinking Water Options in Bangladesh. PloS One. 2013, 8 (1): e53640-10.1371/journal.pone.0053640.CrossRefPubMedPubMedCentral
77.
Olatunji BO, Sawchuk CN, De Jong PJ, Lohr JM: Disgust sensitivity and anxiety disorder symptoms: Psychometric properties of the disgust emotion scale. J Psychopathol Behav Assess. 2007, 29 (2): 115-124. 10.1007/s10862-006-9027-8.CrossRef
78.
Jimerson A, Rosenbaum J, Middlestadt S, Schneider A, Strand J, Mitchell P, Schedchter C, Bender J, French J: Applying the BEHAVE Framework: A Workshop on Strategic Planning for Behavior Change: FacilitatorÆs Guide. 2004, Washington DC: AED
Metadata
Title
The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings
Authors
Robert Dreibelbis
Peter J Winch
Elli Leontsini
Kristyna RS Hulland
Pavani K Ram
Leanne Unicomb
Stephen P Luby
Publication date
01-12-2013
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2013
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/1471-2458-13-1015

Other articles of this Issue 1/2013

BMC Public Health 1/2013 Go to the issue

Research article

A qualitative study of health information technology in the Canadian public health system

Research article

Individual and contextual factors of influence on adherence to antiretrovirals among people attending public clinics in Rio de Janeiro, Brazil

Research article

Violence, mental health and violence risk factors among community women: an epidemiological study based on two national household surveys in the UK

Research article

Gender differences in personality patterns and smoking status after a smoking cessation treatment

Research article

Health coping strategies of the people vulnerable to climate change in a resource-poor rural setting in Bangladesh

Research article

Human H5N1 influenza infections in Cambodia 2005–2011: case series and cost-of-illness