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Rationale: Consistent hand washing with soap can reduce the risk of diarrhea, but changing hand-washing behavior is difficult. Systematic behavior change approaches promise to enhance hand washing with soap effectively, and allow the identification of active intervention ingredients using mediation analysis. This knowledge can then be used to derive hypotheses for systematically refining the intervention., Objective: We demonstrate this at the example of a behavior change intervention to promote hand washing with soap based on the RANAS approach (risk, attitudes, norms, ability, and self-regulation)., Methods: Sixteen wards of Masvingo province in Zimbabwe were randomly allocated to the RANAS-based intervention or a wait-list control group. Hand washing at baseline and follow-up was observed for 224 randomly selected caregivers of young children. They additionally participated in quantitative face-to-face interviews assessing psychosocial factors., Results: At baseline, hand washing with soap was <3% on average, and did not differ between groups (p = .526). At follow-up, intervention participants washed hands with soap more frequently than controls (in 29.4% vs. 8.2% of all stool- and food-related situations, B = 1.88, SE = 0.32, OR = 6.6, p < .001). Mediation analyses revealed that the intervention enhanced several of the targeted psychosocial factors; return, descriptive and injunctive norms, action knowledge, action self-efficacy, maintenance self-efficacy, action planning, and remembering. The intervention effect was mediated through increased remembering., Conclusion: This study supports the efficacy of a systematic approach to behavior change to promote hand washing with soap. The analyses of the mechanisms revealed important insights into the active ingredients of the intervention, which will facilitate its future refinement., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Rationale: Many behaviours relevant to public health are part of everyday routines. However, few tools exist to study such behaviours. Here we re-introduce the behaviour setting, an ecological psychological concept developed in the 1950s, as an approach to the study of routine behaviour. The setting concept bridges theoretical and applied approaches in sociology, psychology and social practice; its components include stage, infrastructure, props, roles, norms, competencies, objectives and resultant routines., Methods: We applied settings theory to health-related water use behaviour in rural Nigeria. We captured the dimensions of water use behaviour settings in 23 households at varying distances from newly-introduced kiosks selling purified water., Results: We found that routines concerning drinking, laundering, dish washing and handwashing were stable in their settings, varying little between households or by type of water source. Hygiene routines were suboptimal but drinking water was carefully segregated. The majority of water use behaviour was governed, not by an immediate desire to maximise health, but by long-established routines embedded in the social, technical and physical environment. Water kiosks are making only marginal improvements to the quantity and quality of water being used in homes., Conclusions: Improving public health will require the disruption of settings, for example, through bringing water infrastructure directly to the home, through the sale of new props that facilitate hygienic routines, or in the disruption of gender roles via the promotion of new norms. Settings are an ecologically valid, meso-level theoretical approach that link social and techno-physical environmental factors to behaviour. They provide a comprehensive framework within which to judge avenues for changing routine behaviours. The behaviour settings tool we developed was easy to use, provided a systematic means of capturing the determinants of routine behaviour, and the findings offered insight into methods for disrupting such behaviour., (Copyright © 2019. Published by Elsevier Ltd.)