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

Abstract

This study reports the impact of the HiFive program, a 6-week handwashing campaign that targets social and emotional motivators to improve student handwashing in primary schools in the Philippines. We designed a clustered randomized trial to evaluate the impact of HiFive on student handwashing behavior, motivation, and access. Of the sample of 196 primary schools located in two districts, half were randomly assigned to receive the program in the 2017-2018 school year. Survey and observation data were collected 3 months after the conclusion of the campaign. In control schools, only 2.5% of students were observed washing their hands with soap and water, our primary outcome and 14.8% were observed washing their hands with at least water. HiFive led to a 3.7 percentage point (p.p.) increase (P < 0.01) in the rate of handwashing with soap and water and a 5.6 p.p. increase (P = 0.03) in handwashing with at least water after toilet use. HiFive also led to a 10.8 p.p. (P < 0.01) increase in the number of handwashing facilities stocked with soap. The program had limited impact on the motivators targeted by the program, suggesting that the small improvements in handwashing may have been driven by increases in the availability of soap. More research is needed to understand how interventions can effectively trigger social motivators to improve handwashing behavior among schoolchildren, and whether the effectiveness of these programs can be augmented with "nudge"-based interventions from the behavioral sciences.

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].…”

“…Half of the included studies were conducted in Asia (16 records), with India making up the largest cohort of studies [39, 44, 47, 48, 57, 63, 68], followed by Bangladesh [38, 41, 50, 59], the Philippines [51, 54] Nepal [49], and Iraq [69]. One study was conducted in both Bangladesh and Kenya [60].…”

“…Eight studies took place in an urban/peri-urban setting, of which 6 studies specified a low-income/slum context [38, 42, 59, 60, 63, 67], the remaining 2 did not specify the context of the setting [43, 56]. A total of 8 studies specifically targeted schools [50, 51, 54, 57, 62, 65, 66, 70], and one study focused on a humanitarian emergency setting [69].…”

“…The participants included only mothers or caregivers of children under the age of 5 (5 records [38, 46, 47, 49, 58]), both caregivers and children (2 records [57, 63]), and only including children (8 records [42, 50, 51, 54, 62, 66, 69, 70]). Several studies targeted an entire household (8 records [39-41, 43, 47, 48, 60, 68]) or the entire community (7 records [44, 53, 55, 56, 59, 61, 64]), whilst a fewer records specified targeting the school community [65], young women [52], or users of a certain facility with specified traits such as shared compound toilets [67].…”

“…The studies targeted specific behaviors rather than diseases and merely described possible health effects of these behaviors, mostly a decrease of infectious pathogens causing a host of illnesses (e.g., diarrhea, pneumonia). Half of the studies targeted handwashing with soap (HWWS) or simply handwashing (17 records [38-42, 46, 50, 51, 53, 54, 57, 59, 62, 63, 65, 69, 70]). Seven studies targeted defecation behaviors such as latrine usage, building or cleaning, and safe disposal of child feces [44, 47, 48, 61, 64, 67, 68], 4 studies focused on water disinfection through chlorination or solar disinfection [52, 56, 58, 60], 2 studies targeted a mix of food hygiene behaviors [45, 49], one study each targeted drug intake for deworming [55], face washing [66], and engaging the population to participate in an indoor residual spraying (IRS) campaign [43].…”