Nudges in the Restroom: How Hand-Washing Can Be Impacted by Environmental Cues

Blackwell, Calvin; Goya‐Tocchetto, Daniela; Sturman, Zachary

doi:10.2139/ssrn.3007866

Cited by 8 publications

(17 citation statements)

References 23 publications

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“…25 Examples of nudges include the rearrangement of food on supermarket shelves to place healthy options at eye level (increasing healthy nutrition), displaying arrows leading to sinks in public restrooms (increasing handwashing), or pasting stickers in the centre of men's urinals (decreasing urinal spillage due to men aiming at the stickers). [26][27][28] Evidence suggests that instead of allocating considerable cognitive resources to make a 'rational' or 'smart' decision, people tend to choose what is easily accessible. 28 29 In this vein, nudging has been shown to be effective in the context of various health promotion strategies such as increasing healthy food choices and dietary change, 30 31 self-management of chronic diseases, 32 and improving HIV and malaria testing.…”

Section: What Do the New Findings Imply?mentioning

confidence: 99%

Nudging toward vaccination: a systematic review

et al. 2021

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BackgroundVaccine hesitancy (VH) and the global decline of vaccine coverage are a major global health threat, and novel approaches for increasing vaccine confidence and uptake are urgently needed. ‘Nudging’, defined as altering the environmental context in which a decision is made or a certain behaviour is enacted, has shown promising results in several health promotion strategies. We present a comprehensive synthesis of evidence regarding the value and impact of nudges to address VH.MethodsWe conducted a systematic review to determine if nudging can mitigate VH and improve vaccine uptake. Our search strategy used Medical Subject Headings (MeSH) and non-MeSH terms to identify articles related to nudging and vaccination in nine research databases. 15 177 titles were extracted and assessed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final list of included articles was evaluated using the Mixed Methods Appraisal Tool and the Grading of Recommendations, Assessment, Development and Evaluations framework.FindingsIdentified interventions are presented according to a framework for behaviour change, MINDSPACE. Articles (n=48) from 10 primarily high-income countries were included in the review. Nudging-based interventions identified include using reminders and recall, changing the way information is framed and delivered to an intended audience, changing the messenger delivering information, invoking social norms and emotional affect (eg, through storytelling, dramatic narratives and graphical presentations), and offering incentives or changing defaults. The most promising evidence exists for nudges that offer incentives to parents and healthcare workers, that make information more salient or that use trusted messengers to deliver information. The effectiveness of nudging interventions and the direction of the effect varies substantially by context. Evidence for some approaches is mixed, highlighting a need for further research, including how successful interventions can be adapted across settings.ConclusionNudging-based interventions show potential to increase vaccine confidence and uptake, but further evidence is needed for the development of clear recommendations. The ongoing COVID-19 pandemic increases the urgency of undertaking nudging-focused research.PROSPERO registration numberCRD42020185817.

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Section: What Do the New Findings Imply?mentioning

confidence: 99%

Nudging toward vaccination: a systematic review

et al. 2021

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“…In comparison to similar studies, our effect size of 17.3 pp on the handwashing with water and soap rate is moderate. It is higher than the results of a study using arrows pointing to handwashing stations in the United States in adult bathrooms, 26 but lower than the impact estimates of several studies testing a variety of nudges in other resource-poor school settings. 24,25 A notable feature of the research design-collecting one round of handwashing data at endline rather than two rounds at baseline and endline as is often standard in randomized trials, was also appropriate in the context of this study.…”

Section: Discussionmentioning

confidence: 59%

“…25 A similar study using contextual cues in the United States (in the form of red arrows leading from toilet stalls to the sink) increased handwashing by 6 pp, from 43.5% to 49.5%. 26 A different approach was used in Naluonde et al (2019) a bar of antibacterial soap threaded with a piece of rope functioned as a hall pass and was given to students going to school pit-latrines by a teacher (during class) or student monitor (during breaks); in a randomized trial, authors found handwashing with soap (HWWS) increased by 8%. 27 We build on this nascent literature by evaluating the impact of a behavioral nudges intervention on student handwashing after toilet use in public elementary schools in the Philippines.…”

Section: Introductionmentioning

confidence: 99%

Nudging Handwashing among Primary School Students in the Philippines: Evidence from a Cluster Randomized Trial

Huang

Le²,

Battle³

et al. 2021

The American Journal of Tropical Medicine and Hygiene

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Handwashing is key to preventing the transmission of various infectious diseases of which school-aged children are particularly susceptible. Traditional, information-messaging campaigns may increase handwashing awareness but have had limited success in promoting behavior change. Behavioral economics “nudges,” which explicitly target the knowledge-behavior gap, is a promising alternative. We evaluate the impact of school-based nudges in the first fully powered cluster randomized controlled trial in the Philippines. Out of our sample of 132 eligible schools, we randomly assigned half to receive nudges, including contextual cues (painted footpath from toilet to handwashing station) and visible reminders (posters and eye sticker), and half to the control group. Four months after implementation, we measured handwashing with soap (HWWS) after toilet use among grades 1–6 students using direct observation and compared this outcome between treatment and control schools. We also assessed whether nudges increased soap availability. The intervention increased HWWS rates by 17.3% points (pp), [95% CI: 4.2, 30.4] in treatment schools from the control group mean of 11.7%. The effect size was comparable across gender and age groups. Access to functioning handwashing facilities with soap increased by 36% (+20.2 pp, 95% CI: 10.9, 29.4). Mediation analysis suggests the program simultaneously nudged students to wash hands with soap in classrooms that already had soap, and nudged teachers to provide soap where it was not already available. These findings demonstrate that behavioral nudges costing less than $70 per school can lead to significant increases in HWWS among students 4 months post-intervention.

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“…In hospitals, universities, and public schools in low-income settings, nudges in public restrooms such as eyes near handwashing stations and arrows pointing from the toilet to the sink have been found to increase rates of HWWS. 38 , 39 A proof-of-concept study of a nudge-based intervention targeting handwashing in Bangladeshi schools found that HWWS rates increased 14 p.p. when handwashing infrastructure was moved closer to toilet facilities, but 52 p.p.…”

Section: Discussionmentioning

confidence: 99%

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

Jetha

Bisserbe

McManus

et al. 2021

The American Journal of Tropical Medicine and Hygiene

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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.

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Nudges in the Restroom: How Hand-Washing Can Be Impacted by Environmental Cues

Cited by 8 publications

References 23 publications

Nudging toward vaccination: a systematic review

Nudging toward vaccination: a systematic review

Nudging Handwashing among Primary School Students in the Philippines: Evidence from a Cluster Randomized Trial

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

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