A disruptive cue improves handwashing in school children in Zambia

Abstract

Behavioral economics hold great promise in changing patterns of behavior that influence human health. Handwashing with soap is one such behavior that is important in reducing exposure to pathogens, and in school-age children, handwashing helps reduce absenteeism through the prevention of respiratory and diarrheal diseases. However, the gap between knowledge on the importance of handwashing and actual handwashing practice, especially with soap, persists. Many traditional behavior change communication approaches have failed in achieving and sustaining improved handwashing practices. Cognitive psychology research on habits as well as nudge theory, a component of behavioral economics predicated on the idea of making a behavior as easy as possible to do, suggests that introducing a disruptive cue into the environment may be able to interrupt current habitual neurological patterns to effect and then sustain behavior change. We used a participatory process to identify and introduce a locally appropriate disruptive cue to improve handwashing behavior in schools in Zambia. We then utilized a school-randomized controlled trial to test the soap-on-a-rope in 50 government schools in Namwala District of Southern Province. Two outcomes were considered among school children; washing hands with water and using soap while washing hands. Following the intervention, soap use was more likely in intervention schools than control schools [Odds ratio = 7.23, 95% confidence interval = (1.76–29.71)], though both intervention and control schools saw an increase in handwashing without soap. This low-cost intervention could be scaled throughout Zambia and may work well in other countries of similar circumstances.

A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children

“…As a reminder the studies were assessed with five stars, where four stars were allocated based on the percentage of assessment criteria met, and one star was added to studies that used a randomized controlled trial methodology. Of the 29 studies included, 2 studies received one star [36,44], 21 received three stars, 2 received four stars [6,43], and 4 received two stars [25,27,32,33].…”

“…None of the interventions involved comparison of outcomes, regulation, self-belief, or covert learning. The interventions included as few as one BCT cluster [43][44][45] and as many as nine [34,42]. Of the 29 included studies, 3 used a single BCT cluster, 15 included 2 to 4, and 11 included 5 or more.…”

Hand hygiene intervention to optimize helminth infection control: Design and baseline results of Mikono Safi–An ongoing school-based cluster-randomised controlled trial in NW Tanzania

“…This was reinforced by sharing children's stool test results with their own parents after explaining transmission routes. Nudges to encourage handwashing with soap have been successfully applied in two previous trials but have not been examined with respect to their effect on STH infection [27,28].…”

Can Social Motivators Improve Handwashing Behavior among Children? Evidence from a Cluster Randomized Trial of a School Hygiene Intervention in the Philippines

“…41 In Zambian public schools, a simple toilet pass fashioned out of soap attached to a rope was a strong enough contextual cue to motivate student HWWS. 42 Finally, the HiFive program may have had a sound conceptual basis but was less effective at improving rates of HWWS because of limitations in the implementation design. Specifically, teachers reported that they felt insufficiently trained to deliver all of the activities in the HiFive curriculum.…”