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

Abstract

Abstractobjective To determine the impact of environmental nudges on handwashing behaviours among primary school children as compared to a high-intensity hygiene education intervention.methods In a cluster-randomised trial (CRT), we compared the rates of handwashing with soap (HWWS) after a toileting event among primary school students in rural Bangladesh. Eligible schools (government run, on-site sanitation and water, no hygiene interventions in last year, fewer than 450 students) were identified, and 20 schools were randomly selected and allocated without blinding to one of four interventions, five schools per group: simultaneous handwashing infrastructure and nudge construction, sequential infrastructure then nudge construction, simultaneous infrastructure and highintensity hygiene education (HE) and sequential handwashing infrastructure and HE. The primary outcome, incidence of HWWS after a toileting event, was compared between the intervention groups at different data collection points with robust-Poisson regression analysis with generalised estimating equations, adjusting for school-level clustering of outcomes.results The nudge intervention and the HE intervention were found to be equally effective at sustained impact over 5 months post-intervention (adjusted IRR 0.81, 95% CI 0.61-1.09). When comparing intervention delivery timing, the simultaneous delivery of the HE intervention significantly outperformed the sequential HE delivery (adjusted IRR 1.58 CI 1.20-2.08), whereas no significant difference was observed between sequential and simultaneous nudge intervention delivery (adjusted IRR 0.75, 95% CI 0.48-1.17).conclusion Our trial demonstrates sustained improved handwashing behaviour 5 months after the nudge intervention. The nudge intervention's comparable performance to a high-intensity hygiene education intervention is encouraging.

The Critical Role of Compliance in Delivering Health Gains from Environmental Health Interventions

“…24,25 Future interventions may also benefit from the explicit inclusion of supplementary behavioral interventions designed to improve compliance. 26…”

Determinants of Clean Birthing Practices in Low- and Middle-Income Countries: a Scoping Review

“…access to infrastructure) as key determinants of clean birthing practices. This is surprising given the body of evidence suggesting that while knowledge and access to materials are necessary precursors for improved hygiene practices these determinants alone are not sufficient to ensure adoption of behaviours ( [73][74][75][76][77][78]). Studies of handwashing behaviour outside of the perinatal period place a much greater emphasis on factors such as social opportunity and automatic motivation.…”

Determinants of Clean Birthing Practices in Low- and Middle-Income Countries: a Scoping Review

“…For example, of the 13 studies that focus on determinants of hand hygiene, the most investigated determinants are knowledge (n=8, 62%), materials/supplies (n=6, 46%) and infrastructure (n=3, 23%). This is surprising given the body of evidence suggesting that while knowledge and access to materials are necessary precursors for improved hygiene practices these determinants alone are not sufficient to ensure adoption of behaviours ( [74][75][76][77][78][79]). Studies of handwashing behaviour outside of the perinatal period place a much greater emphasis on factors such as social opportunity and automatic motivation.…”