Handwashing with soap, exclusive breastfeeding and the use of oral rehydration
salts and zinc to manage diarrhoea episodes are apparently simple practices
through which many child deaths from diarrhoea could be prevented. However,
their success depends on caregiver behaviour, which has proved difficult to
influence. This thesis describes the development and evaluation of a theory-based,
multiple behaviour change intervention to improve uptake of these diarrhoea
control practices in Lusaka Province, Zambia.
The research was guided by a conceptual framework based on an ecological theory
of behaviour and comprised three studies: formative research, outcome evaluation
and process evaluation. Formative research focussed on actual practices of target
behaviours and their determinants and informed the design of an intervention
based on the motive affiliation. Outcome evaluation used a cluster-randomised
trial to assess the effect of the intervention on handwashing with soap, exclusive
breastfeeding, and use of oral rehydration salts and zinc to manage childhood
diarrhoeal episodes. The intervention resulted in a small improvement in reported
practice of exclusive breastfeeding. Changes in the other target behaviours were
observed in areas where higher reach was achieved. The process evaluation used
mixed methods and was guided by the intervention’s theory of change to explore
how intervention content and delivery influenced behavioural outcomes. The
process evaluation revealed that the intervention was popular and memorable, but
it achieved low and variable levels of reach and did not change psychological
mediators of behaviour.
This research adds to the currently small evidence base in the field of multiple
behaviour change for diarrhoea control. In light of the findings of low reach,
further work is needed to ascertain whether delivery alone is the issue, or whether
the intervention content also requires revision. The findings underscore the
importance of modifying intervention delivery strategies to account for the local
context.