Psychosocial Factors Mediating the Effect of the CHoBI7 Intervention on Handwashing With Soap: A Randomized Controlled Trial

Christine Marie George, Shwapon Biswas, Danielle Jung, Jamie Perin, Tahmina Parvin, Shirajum Monira, K. M. Saif-Ur-Rahman, Mahamud Ur Rashid, Sazzadul Islam Bhuyian, Elizabeth D. Thomas, Robert Dreibelbis, Farzana Begum, Fatema Zohura, Xiaotong Zhang, David A. Sack, Munirul Alam, R. Bradley Sack, Elli Leontsini, Peter J. Winch

Research output: Contribution to journalArticlepeer-review


Inadequate hand hygiene is estimated to result in nearly 300,000 deaths annually, with the majority of deaths being among children younger than 5 years. In an effort to promote handwashing with soap and water treatment behaviors among highly susceptible household members of cholera patients, we recently developed the Cholera-Hospital-Based Intervention-for-7-Days (CHoBI7); chobi means picture in Bengali. This 1-week handwashing with soap and water treatment intervention is delivered by a promoter in the hospital and the home to cholera patients and their household members. In our randomized controlled trial of this intervention, we observed a significant reduction in symptomatic cholera infections during the 1-week intervention period compared to the control arm and sustained high uptake of observed handwashing with soap behaviors up to 12 months postintervention. The aim of the present study was to assess the underlying mechanism of change that led to the high handwashing with soap behavior observed among participants who received the CHoBI7 intervention. Handwashing with soap was measured using 5-hour structured observation, and psychosocial factors were assessed using a structured questionnaire among 170 intervention and 174 control household members enrolled in the CHoBI7 trial. To investigate potential mediators of the CHoBI7 intervention effect, mediation models were performed. Response efficacy was found to mediate the intervention’s effect on habit formation for handwashing with soap at the 1-week follow-up, and disgust, convenience, and cholera awareness were mediators of habit maintenance at the 6- to 12-month follow-up. These results support the use of theory-driven approaches for the development and implementation of handwashing with soap interventions.

Original languageEnglish (US)
Pages (from-to)613-625
Number of pages13
JournalHealth Education and Behavior
Issue number4
StatePublished - Aug 1 2017


  • Bangladesh
  • behavioral interventions
  • behavioral theories
  • diarrhea disease
  • handwashing with soap
  • mediation analysis
  • randomized controlled trial

ASJC Scopus subject areas

  • Arts and Humanities (miscellaneous)
  • Public Health, Environmental and Occupational Health


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