A cluster-randomised trial to evaluate an intervention to promote handwashing in rural Nigeria

Abstract

Handwashing with soap at critical times helps prevent diarrhoeal diseases. Changing handwashing practices through behaviour change communication remains a challenge. This study designed and tested a scalable intervention to promote handwashing with soap. A cluster-randomised, controlled trial compared our intervention against standard practice. Subjects were men, women and children in 14 villages in Cross-River state, Nigeria. The primary outcome was the proportion of observed key events on which hands were washed with soap. Binomial regression analysis calculated prevalence differences between study arms. The intervention had minimal effect on the primary outcome (+2.4%, p = 0.096). The intervention was associated with increased frequency of handwashes without soap before food contact (+13%, p = 0.017). The intervention failed to produce significant changes in handwashing with soap at key times. The low dose delivered (two contact points) may have increased scalability at the cost of effectiveness, particularly in the challenging context of inconvenient water access.

Nudge strategies for behavior-based prevention and control of neglected tropical diseases: a scoping review and ethical assessment

“…During that first modest increase (2010 – 2017), 12 studies were published [39, 41, 46, 49, 56, 59-61, 63-65, 67]. The exponential increase is most noticeable in 2018 resulting in 7 eligible studies [42, 43, 48, 50, 55, 57, 58], while in 2019, there were 9 included studies [38, 44, 45, 52, 54, 62, 66, 69, 70], and finally up until 6 th September 2020 we identified 5 additional studies [40, 47, 51, 53, 68].…”

“…One study was conducted in both Bangladesh and Kenya [60]. The other half of the included studies were conducted in Africa (15 records): four studies in Kenya [52, 55, 66, 70], followed by two in Zimbabwe [53, 56], Nigeria [40], South-Africa [42], Malawi [45], Ethiopia [46], Chad [58], Burundi [61], Zambia [62], Mali [64], Egypt [65], and Uganda [67]. Finally, only one study was identified which took place on the South-American continent: Peru [43].…”

“…A range of intervention strategies were employed across the included studies, with some studies either detailing multiple, combined behavior change strategies (including nudges), others incorporating few strategies, whilst some merely focused on applying one strategy. Half of the eligible studies consisted of a complex intervention (17 records [39, 40, 44, 45, 47, 49, 53, 54, 56-59, 63-66, 68]). Subsequently, a total of 7 ‘moderate intervention’ studies were recorded [41, 43, 46, 48, 51, 60, 70].…”

“…Thirty of the nudges were implemented for HWWS in a total of 17 studies [38-42, 46, 50, 51, 53, 54, 57, 59, 62, 63, 65, 69, 70] (Figure 2). This group of nudges were most diverse and included a range of behavior change strategies, such as the implementation of disruptive cues: colorful, painted footpaths [50, 51]; soap including embedded toys [42, 69]; soap on a rope [62]; posters as reminders [51, 59, 65]; stickers as reminders [39, 41, 51], the implementation of social norms: stickers or certificates as signals of pro-social behavior [39, 40, 59]; role-model display [39]; and public pledges [39, 40, 46, 53, 54, 57, 63, 70] by simplifying information [38] and providing planning reminders [53]. Twelve nudges targeted defecation behaviors in 7 studies [44, 47, 48, 61, 64, 67, 68].…”

“…The most common nudge techniques were those targeting decision assistance, such as “facilitating commitment” (24 nudges), representing both self-commitment (including planning commitment) and public commitment (public pledges) [39, 40, 43-47, 49, 53, 54, 57, 58, 60, 61, 63, 64, 66-68, 70] and “providing reminders” (16 nudges), using posters, stickers, and planning reminders [39, 41, 43, 47, 49-51, 53, 55-57, 59, 62, 65]. Techniques targeting decision structure represented by “change option consequences” only, included 16 nudges using signaling, competitions and lotteries (including toy-soap, since the chances of ‘winning’ the toy depends on the amount of soap used) [39, 40, 42-45, 47, 49, 55, 56, 58, 59, 64, 69]. Finally, decision information was the least used category with 5 nudges using “translate information” through simplification and message reframing [38, 52, 58, 60], 3 nudges using “provide social reference point” referring to role-models [39, 43, 48, 49], and 2 nudges implementing “make information visible” through visualization of the future and providing visual feedback [44, 52].…”