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      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

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          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.

          Related collections

          Most cited references 54

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          In search of how people change. Applications to addictive behaviors.

          How people intentionally change addictive behaviors with and without treatment is not well understood by behavioral scientists. This article summarizes research on self-initiated and professionally facilitated change of addictive behaviors using the key trans-theoretical constructs of stages and processes of change. Modification of addictive behaviors involves progression through five stages--pre-contemplation, contemplation, preparation, action, and maintenance--and individuals typically recycle through these stages several times before termination of the addiction. Multiple studies provide strong support for these stages as well as for a finite and common set of change processes used to progress through the stages. Research to date supports a trans-theoretical model of change that systematically integrates the stages with processes of change from diverse theories of psychotherapy.
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            The Health Belief Model: a decade later.

            Since the last comprehensive review in 1974, the Health Belief Model (HBM) has continued to be the focus of considerable theoretical and research attention. This article presents a critical review of 29 HBM-related investigations published during the period of 1974-1984, tabulates the findings from 17 studies conducted prior to 1974, and provides a summary of the total 46 HBM studies (18 prospective, 28 retrospective). Twenty-four studies examined preventive-health behaviors (PHB), 19 explored sick-role behaviors (SRB), and three addressed clinic utilization. A "significance ratio" was constructed which divides the number of positive, statistically-significant findings for an HBM dimension by the total number of studies reporting significance levels for that dimension. Summary results provide substantial empirical support for the HBM, with findings from prospective studies at least as favorable as those obtained from retrospective research. "Perceived barriers" proved to be the most powerful of the HBM dimensions across the various study designs and behaviors. While both were important overall, "perceived susceptibility" was a stronger contributor to understanding PHB than SRB, while the reverse was true for "perceived benefits." "Perceived severity" produced the lowest overall significance ratios; however, while only weakly associated with PHB, this dimension was strongly related to SRB. On the basis of the evidence compiled, it is recommended that consideration of HBM dimensions be a part of health education programming. Suggestions are offered for further research.
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              Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis.

              To assess the effectiveness of interventions to improve the microbial quality of drinking water for preventing diarrhoea. Systematic review. Cochrane Infectious Diseases Group's trials register, CENTRAL, Medline, Embase, LILACS; hand searching; and correspondence with experts and relevant organisations. Randomised and quasirandomised controlled trials of interventions to improve the microbial quality of drinking water for preventing diarrhoea in adults and in children in settings with endemic disease. Allocation concealment, blinding, losses to follow-up, type of intervention, outcome measures, and measures of effect. Pooled effect estimates were calculated within the appropriate subgroups. 33 reports from 21 countries documenting 42 comparisons were included. Variations in design, setting, and type and point of intervention, and variations in defining, assessing, calculating, and reporting outcomes limited the comparability of study results and pooling of results by meta-analysis. In general, interventions to improve the microbial quality of drinking water are effective in preventing diarrhoea. Effectiveness was not conditioned on the presence of improved water supplies or sanitation in the study setting and was not enhanced by combining the intervention with instructions on basic hygiene, a water storage vessel, or improved sanitation or water supplies--other common environmental interventions intended to prevent diarrhoea. Interventions to improve water quality are generally effective for preventing diarrhoea in all ages and in under 5s. Significant heterogeneity among the trials suggests that the level of effectiveness may depend on a variety of conditions that research to date cannot fully explain.
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                Author and article information

                Contributors
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2013
                26 October 2013
                : 13
                : 1015
                Affiliations
                [1 ]Social and Behavioural Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
                [2 ]Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
                [3 ]Water, Sanitation, and Hygiene Research Group, Centre for Communicable Diseases, icddr,b, Dhaka, Bangladesh
                [4 ]Woods Institute of the Environment, Stanford University, Stanford, CA 94305, USA
                Article
                1471-2458-13-1015
                10.1186/1471-2458-13-1015
                4231350
                24160869
                3d628d29-0206-427d-a40a-7d853b24e392
                Copyright © 2013 Dreibelbis et al.; licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Public health

                behavioural theory, behaviour change, water, sanitation, hygiene, technology, systematic review

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