Behavior Change without Behavior Change Communication: Nudging Handwashing among Primary School Students in Bangladesh

Abstract

Behavior change communication for improving handwashing with soap can be labor and resource intensive, yet quality results are difficult to achieve. Nudges are environmental cues engaging unconscious decision-making processes to prompt behavior change. In this proof-of-concept study, we developed an inexpensive set of nudges to encourage handwashing with soap after toilet use in two primary schools in rural Bangladesh. We completed direct observation of behaviors at baseline, after providing traditional handwashing infrastructure, and at multiple time periods following targeted handwashing nudges (1 day, 2 weeks, and 6 weeks). No additional handwashing education or motivational messages were completed. Handwashing with soap among school children was low at baseline (4%), increasing to 68% the day after nudges were completed and 74% at both 2 weeks and 6 weeks post intervention. Results indicate that nudge-based interventions have the potential to improve handwashing with soap among school-aged children in Bangladesh and specific areas of further inquiry are discussed.

Comparing the behavioural impact of a nudge‐based handwashing intervention to high‐intensity hygiene education: a cluster‐randomised trial in rural Bangladesh

“…The effect of nudges on handwashing in this RCT was more modest than seen in the pilot project – a 20‐percentage point improvement vs. a 66‐percentage point improvement in the pilot. Baseline handwashing was much higher in this RCT compared to the pilot project.…”

The Impact of a School-Based Water, Sanitation, and Hygiene Program on Absenteeism, Diarrhea, and Respiratory Infection: A Matched–Control Trial in Mali

“…An evaluation of a school WASH program with higher fidelity would likely result in different outcomes, and more evidence on how to improve hygienic behaviors is warranted. Several recent studies have begun to rigorously evaluate behavior change, 24,25 and these lessons should be applied more broadly throughout the sector.…”

Behaviour Centred Design: towards an applied science of behaviour change

“…Examples can be provided from programmes targeting increases in handwashing with soap. Target individuals can be helped to form a habit (reactive control) by placing painted cues to handwashing outside school toilets (Dreibelbis, Kroeger, Hossain, Venkatesh, & Ram, 2016); making hospital rooms smell of lemon can stimulate motivated efforts by caretakers to keep themselves clean (Birnbach, King, Vlaev, Rosen, & Harvey, 2013), or individuals can be encouraged to form plans (executive control) by being reminded of the health benefits of handwashing (Curtis, Danquah, & Aunger, 2009). All three levels of behavioural control may also be required sequentially as part of an overall strategy.…”