Effect of Two Complementary Mass-Scale Media Interventions on Handwashing with Soap among Mothers

"Due to the large reach and on-going marketing investments of companies, the scale at which their marketing messages could drive public health gains through positive behavior change is substantial."

Research has found only about 19% of people worldwide wash their hands with soap at critical times, yet proper hand hygiene is estimated to reduce diarrhoeal disease by about 30%. Receiving hygiene promotion messages in a timely manner has been associated with increased handwashing with soap in an experimental setting (in restrooms). In this context, and guided by the hypothesis that using mass media to reach mothers may result in behaviour change among mothers and their children, this study evaluated 2 complementary interventions designed to increase the frequency of handwashing with soap in India: one using TV advertising, and the other mobile phone messaging.

Lifebuoy, a Unilever soap brand, wanted to understand the potential public health impacts of mass-scale media, and so contracted an independent agency to conduct 2 market research studies:

• In Dhar and Indore, cities in the central Indian state of Madhya Pradesh, mothers of 4- to 12-year-old children (n = 756) were randomly allocated among 4 arms: 3 different branded television commercials (TVCs) and a fourth, control TVC unrelated to handwashing. The TVCs described the problem (illness caused by germs), demonstrated the role of the product in solving that problem, and gave reassurance that the product can adequately address the problem. The TVCs were embedded in blocks of unrelated commercials and shown once a week over 4 weeks in participants' own homes. (One example may be viewed below.)
• In Varanasi, Allahabad, and Gorakhpur in the northern Indian state of Uttar Pradesh, new mothers (n = 598) and mothers of 4- to 7-year-old children (n = 501) were enrolled in a treatment or control arm. Mothers in the treatment arm received branded mobile phone messages twice weekly for 8 weeks (new mothers) or 4 weeks (mothers of 4- to 7-year-olds). The messages were about 90 seconds long and included a jingle to identify and brand the campaign, a dialogue between a fictionalised local doctor and a mother, and then a summary and sign off. The overall tone of the campaign was one of a warm, caring doctor communicating informative and encouraging messages to link the intended behaviours to a mother's desire to nurture her child. Messages to general mothers were about hygiene topics, while messages to new mothers included more general maternal health messages as well.

For TVCs, there were higher rates of handwashing with soap at key occasions in the first (relative risk (RR): 1.33, p = .002) and second (RR: 1.26, p = .041) of 3 treatment arms, or 0.4 additional handwashes with soap on key occasions daily. (When examined afterwards, the particular edit of the third TVC used did not explicitly feature the role of soap as the others did, which may have been one reason for its lack of impact. "This suggests the importance of featuring the role of the product in a behavior that requires a product to perform and that a more attractive product could lead to greater rates of behavior change.")

In the mobile study, new mothers (adj-RR: 1.04, p = .035) and general mothers (RR: 1.07, p = .007) receiving the intervention were more likely to wash their hands with soap on key occasions than those in the control group, corresponding to 1.3 and 1.0 more occasions daily.

The researchers suggest that TVCs can be viewed by multiple family members together, perhaps leading to more impact or stimulating dialogue within the family. However, less than half of households have access to a television in India, while mobile phones are widespread in that country. Furthermore, mobile technology allows intervention content to be more tailored to the audience. In short, say the researchers, the comparative effectiveness of different channels should be investigated more in the future.

"Compared to intensive interpersonal programs, the observed effect sizes were relatively small. This is consistent with the literature demonstrating the importance of the enabling environment for handwashing behavior change..." Nonetheless, "[t]he combined results, with mobile as a way to reach those without access to television, bolster the case for using relatively cheap and easily scalable interventions to induce behaviour change across large segments of the population, with potential synergies when used in tandem with traditional, on-the-ground programs."

One implication of the research is that it could be beneficial for traditional public health actors to partner with brands to improve population health outcomes at scale in a cost-effective and sustainable way.