Identifying psychosocial determinants of water, sanitation, and hygiene (WASH) behaviors for the development of evidence-based Baby WASH interventions (REDUCE program)

Diarrheal disease remains a leading cause of child mortality, globally. In the Democratic Republic of the Congo (DRC), each year there are an estimated 45 million episodes of diarrhea in children under five years of age. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to develop theory-driven, evidence-based approaches to reduce diarrheal diseases among young children. The REDUCE prospective cohort study in Walungu Territory in Eastern DRC took guidance from the risks, at-titudes, norms, abilities, and self-regulation model, the integrated behavioral model for water, sanitation, and hygiene (WASH), and other behavior change theories to identify psychosocial factors associated with WASH behaviors. Psychosocial factors were measured among 417 caregivers at baseline and caregiver responses to child mouthing of dirty fomites and handwashing with soap was assessed by 5-hour structured observation at the 6-month follow-up. Caregivers who agreed that their child could become sick if they put dirt in their mouth (perceived susceptibility) and caregivers that agreed they could prevent their child from playing with dirty things outside (self-efficacy) were significantly more likely to stop their child from mouthing a dirty fomite. Higher perceived susceptibility, self-efficacy, and disgust, and lower dirty reactivity, were associated with higher handwashing with soap behaviors. This study took a theory-driven and evidence-based approach to identify psychosocial factors to target for intervention development. The findings from this study informed the devel-opment of the REDUCE Baby WASH Modules that have been delivered to over 1 million people in eastern DRC.