Thinking Outside the Soapbox: Evaluating the Effectiveness of a Community-based Hygiene Promotion Intervention in Santa Clara, El Salvador Open Access
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Due to the lack of adequate hygiene, potable water and sanitation, diarrheal disease still poses a considerable threat to the health and well-being of developing communities worldwide. While there have been considerable advances in the areas of potable water and sanitation, there is still a lack of evidence on theory-based program models for hygiene behavior change. This intervention research study aimed to advance knowledge around hygiene behavior change strategies through the evaluation of a two-year community-based hygiene promotion pilot project implemented in rural Santa Clara, El Salvador by local health promoters. This quasi-experimental study examined whether the program achieved changes in hygiene knowledge and behavior and what features accounted for the successes or failures of the program in this context. Informed by Everett Rogers' Diffusion of Innovations (DOI) theory, this study also examined the role of the health promoters as change agents and the process of hygiene behavior change. Through examination of the message source in hygiene behavior adoption, this research offers a deeper understanding of this theoretical approach and intervention strategy, providing further justification for the theoretical basis of hygiene interventions in a Latin American community context. Results of this study showed improvements in hygiene knowledge as well as improvements in hygiene behaviors related to sanitation and food hygiene. Study results also suggest that limited improvements in water and domestic hygiene may be related to an inadequate enabling environment for behavior change, with source of water and availability of mechanisms for adequate trash disposal playing a role in this process. Furthermore, this study showed that program successes may be attributed to the community-based approach and intervention delivery by local health promoters, who played a vital role in the acceptance of hygiene messages by community members. Health promoter characteristics (some of which were DOI-related) that were identified as important to hygiene behavior change communication included: amabilidad (kindness), respeto (respect), confianza (trust), homophily, effort, and credibility. Attributes related to the hygiene behaviors being promoted that influenced adoption of practices were: compatibility with daily life, relative advantages that they offered (such as improved health, community cleanliness and reduction of pests), and easiness to observe and perform the practices. The ama de casa, or female homemaker, emerged as a key player in the hygiene behavior adoption process, serving as a secondary change agent to the health promoters. Community social-structural characteristics (e.g., social networks) were also identified as playing an important role in hygiene behavior adoption. Finally, the formation of habit, knowledge of the causes of diarrhea, obedience to authority and dedication to community priorities emerged as possible motivators for hygiene behavior. Recommendations for public health practice and research as well as theoretical implications are offered.