Evidence on Demand was requested by DFID to undertake a rapid desk-based study to assess the level of change in handwashing with soap that could be expected from a successful hygiene promotion intervention in a low or middle-income country setting. As part of this task, a summary of factors that may influence intervention outcomes and sustainability is provided.
The objective of the review was to identify the level of behaviour change, in this case handwashing with soap, the various interventions were able to achieve. This review focussed on published peer-reviewed articles as well as programme reports and other grey literature providing evidence of behaviour change. The authors primarily reviewed mainstream research published in the last 10 years. In order to be included in the review, the manuscript or report needed to include information on an intervention to promote handwashing with soap, or an evaluation thereof, be delivered in a low or middle income country, be available in English and preferably have a behaviour outcome or a health outcome with considerable data on behaviour.
Only eight successful interventions were included as part of this review. These comprise both large-scale and smaller-focussed interventions, in various settings, using different approaches. These interventions have shown that achievable handwashing behaviour change ranges between 14%-67% increases in handwashing behaviour as measured by observation (sustained changes - 45 day to 18 months) and between 4%-46% as measured by self-report (post intervention and continuous assessment). Measures of sustainability of interventions are limited; one intervention showed sustained behaviour up to 45 days, and data from two interventions show that change in behaviour was sustained for at least 12 months. One intervention has been assessed after five years, and still shows evidence of the sustained behaviour.
All interventions provided data on handwashing at key times, and the majority measured handwashing through observation with only one using only self-report. Most interventions used multiple methods. Spot checks of facilities and handwashing demonstrations were additional proxy measures used in some of the reviewed interventions.
In two of the interventions, soap for handwashing was provided as part of the intervention and in all the interventions soap use was mentioned. Water availability was limited in three of the eight included interventions.
It was found that handwashing reminders, such as stickers with eyes at the designated handwashing facility, can be used to prompt handwashing behaviour. In addition, knowledge of key handwashing times, or good handwashing ‘technique’ does not necessarily translate into handwashing habit, nor does the provision of a handwashing facility automatically translate into use.
Due to the wide variation in setting and context in which the eight interventions were implemented, the results cannot be directly compared to draw out ‘best approaches’. In addition, the interventions included measure a range of handwashing behaviours, for example after visiting a toilet or before eating—these different measures are likely to have varied effects of the levels of behaviour change observed, and thus makes direct comparison difficult. However, the majority of included interventions considered underlying theories of behaviour change. Overall, key factors which may contribute towards a successful behaviour change intervention include extensive formative research to understand the target population, duration of follow up (as well as number of follow up points) after intervention, baseline levels of handwashing behaviour and the key handwashing times which are targeted. Overall, this area of research would benefit from for rigorous impact and process evaluation, subsequent modification of intervention design, and further testing of ‘new generation’ handwashing with soap interventions. In addition, evidence of cost would be beneficial, as this would help determine which successful interventions can also be implemented in a cost-effective manner.
This report has been produced for Evidence on Demand with the assistance of the UK Department for International Development (DFID) contracted through the Climate, Environment, Infrastructure and Livelihoods Professional Evidence and Applied Knowledge Services (CEIL PEAKS) programme, jointly managed by DAI (which incorporates HTSPE Limited) and IMC Worldwide Limited.
Heijnen, M.; Greenland, K. Level of behaviour change achievable by handwashing with soap interventions: a rapid review. Evidence on Demand, UK (2015) v + 30 pp. [DOI: 10.12774/eod_hd.april2015.heijnenmetal]