Volume 99, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Changing hand hygiene behavior at scale in the community remains a challenge. The objective of this study was to estimate the effect of Unilever’s school-based “School of 5” handwashing campaign on handwashing with soap (HWWS) in schoolchildren and their mothers in the Indian state of Bihar. We conducted a cluster-randomized trial in two districts. We randomized a total of 32 villages with at least one eligible school to intervention and control groups (1:1) and recruited 338 households in each group for outcome measurement. We used structured observation in households to measure HWWS at target occasions (after defecation, soap use during bathing, and before each main meal) in schoolchildren and their mothers. Observers were blinded to intervention status. We observed 636 target occasions (297 in the intervention arm and 339 in the control arm) in mothers and school-going children. After the intervention, HWWS prevalence at target occasions was 22.4% in the control arm and 26.6% in the intervention arm (prevalence difference +4.4%, 95% confidence interval: −4.0, 12.8). The difference was similar in children and mothers. Observers appeared to be adequately blinded to intervention status, whereas observed households were successfully kept unaware of the purpose of observations. To conclude, we found no evidence for a health-relevant effect of the School of 5 intervention on HWWS in schoolchildren and their mothers. Qualitative research suggested that reasons for the low impact of the intervention included low campaign intensity, ineffective delivery, and a model possibly not well tailored to these challenging physical and social environments.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. Aiello AE, Coulborn RM, Perez V, Larson EL, , 2008. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. Am J Public Health 98: 13721381. [Google Scholar]
  2. Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA, , 2008. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev CD004265. [Google Scholar]
  3. Cowling BJ, 2009. Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial. Ann Intern Med 151: 437446. [Google Scholar]
  4. Rabie T, Curtis V, , 2006. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11: 258267. [Google Scholar]
  5. Emerson PM, Cairncross S, Bailey RL, Mabey DC, , 2000. Review of the evidence base for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma control. Trop Med Int Health 5: 515527. [Google Scholar]
  6. Manandhar DS, Members of the MIRA Makwanpur trial team , 2004. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 364: 970979. [Google Scholar]
  7. Bieri FA, 2013. Health-education package to prevent worm infections in Chinese schoolchildren. N Engl J Med 368: 16031612. [Google Scholar]
  8. Curtis VA, Danquah LO, Aunger RV, , 2009. Planned, motivated and habitual hygiene behaviour: an eleven country review. Health Educ Res 24: 655673. [Google Scholar]
  9. Freeman MC, 2014. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health 19: 906916. [Google Scholar]
  10. Biran A, Schmidt WP, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, Gopalan B, Aunger R, Curtis V, , 2014. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health 2: e145e154. [Google Scholar]
  11. Biran A, 2009. The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial. Trop Med Int Health 14: 13031314. [Google Scholar]
  12. Bowen A, Ma H, Hoeckstra P, Luby S, , 2005. Effect of a handwashing promotion program in Chinese primary schools. Am J Trop Med Hyg 73: 70. [Google Scholar]
  13. Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, Hoekstra RM, Luby S, , 2007. A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. Am J Trop Med Hyg 76: 11661173. [Google Scholar]
  14. Huda TM, Unicomb L, Johnston RB, Halder AK, Yushuf Sharker MA, Luby SP, , 2012. Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh. Soc Sci Med 75: 604611. [Google Scholar]
  15. Mason-Jones AJ, Sinclair D, Mathews C, Kagee A, Hillman A, Lombard C, , 2016. School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents. Cochrane Database Syst Rev 11: CD006417. [Google Scholar]
  16. Lopez LM, Bernholc A, Chen M, Tolley EE, , 2016. School-based interventions for improving contraceptive use in adolescents. Cochrane Database Syst Rev CD012249. [Google Scholar]
  17. Freeman MC, Greene LE, Dreibelbis R, Saboori S, Muga R, Brumback B, Rheingans R, , 2011. Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Trop Med Int Health 17: 380391. [Google Scholar]
  18. Blanton E, Ombeki S, Oluoch GO, Mwaki A, Wannemuehler K, Quick R, , 2010. Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households—Nyanza Province, western Kenya, 2007. Am J Trop Med Hyg 82: 664671. [Google Scholar]
  19. O’Reilly CE, Freeman MC, Ravani M, Migele J, Mwaki A, Ayalo M, Ombeki S, Hoekstra RM, Quick R, , 2008. The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, western Kenya, 2006. Epidemiol Infect 136: 8091. [Google Scholar]
  20. Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R, , 2014. The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: a cluster-randomized trial in Kenya. Am J Public Health 104: e91e97. [Google Scholar]
  21. Nicholson JA, Naeeni M, Hoptroff M, Matheson JR, Roberts AJ, Taylor D, Sidibe M, Weir AJ, Damle SG, Wright RL, , 2014. An investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in Indian urban communities. Trop Med Int Health 19: 284292. [Google Scholar]
  22. Keogh-Brown MR, 2007. Contamination in trials of educational interventions. Health Technol Assess 11: iii, ix107. [Google Scholar]
  23. Aunger R, Curtis V, , 2013. The Evo-Eco approach to behaviour change. Lawson D, Gibson M, eds. Applied Evolutionary Anthropology Advances in the Evolutionary Analysis of Human Behaviour, Vol. 1. New York, NY: Springer. Available at: http://www.hygienecentral.org.uk/pdf/aunger-curtis-the-evo-eco-approach.pdf.
  24. Curtis V, de Barra M, Aunger R, , 2011. Disgust as an adaptive system for disease avoidance behaviour. Philos Trans R Soc Lond B Biol Sci 366: 389401. [Google Scholar]
  25. Seimetz E, Kumar S, Mosler HJ, , 2016. Effects of an awareness raising campaign on intention and behavioural determinants for handwashing. Health Educ Res 31: 109120. [Google Scholar]
  26. Galiani S, Gertler P, Ajzenman N, Orsola-Vidal A, , 2016. Promoting handwashing behavior: the effects of large-scale community and school-level interventions. Health Econ 25: 15451559. [Google Scholar]
  27. Briceno B, Coville A, Gertler P, Martinez S, , 2017. Are there synergies from combining hygiene and sanitation promotion campaigns: evidence from a large-scale cluster-randomized trial in rural Tanzania. PLoS One 12: e0186228. [Google Scholar]
  28. Ram PK, 2010. Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation. Am J Trop Med Hyg 83: 10701076. [Google Scholar]

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  • Received : 05 Mar 2018
  • Accepted : 13 Jun 2018
  • Published online : 13 Aug 2018

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