Author:
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Reference Manager
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-
1.
Pogrebna G, Kharlamov A, 2020. The impact of cross-cultural differences in handwashing patterns on the COVID-19 outbreak magnitude. Regulation and Governance.
-
2.
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: 1372–1381.
-
3.
Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 2151–2161.
-
4.
Maleta KM, Manary MJ, 2019. WASH alone cannot prevent childhood linear growth faltering. Lancet Glob Health 7: e16–e7.
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5.
Cumming O, Curtis V, 2018. Implications of WASH benefits trials for water and sanitation. Lancet Glob Health 6: e613–e4.
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6.
UNICEF, 2019. Position Paper: Implications of Recent WASH and Nutrition Studies for WASH Policy and Practice 2019. Geneva, New York: UNICEF. Available at: https://www.who.int/water_sanitation_health/news-events/who-unicef-position-paper-on-wash-and-nutrition-studies-20191125.pdf.
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7.
Chase C, Do Q-T, 2012. Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam. New York, NY: The World Bank.
-
8.
Rosen L, Manor O, Engelhard D, Brody D, Rosen B, Peleg H, Meir M, Zucker D, 2006. Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools. Prev Med 42: 27–32.
-
9.
Watson JA, Ensink JH, Ramos M, Benelli P, Holdsworth E, Dreibelbis R, Cumming O, 2017. Does targeting children with hygiene promotion messages work? The effect of handwashing promotion targeted at children, on diarrhoea, soil‐transmitted helminth infections and behaviour change, in low‐and middle‐income countries. Trop Med Int Health 22: 526–538.
-
10.
Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP, 2000. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 160: 1017–1021.
-
11.
Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW, 1990. Increasing ICU staff handwashing: effects of education and group feedback. Infect Control Hosp Epidemiol 11: 191–193.
-
12.
Jetha Q, Bisserbe C, McManus J, Waldroop D, Naliponguit EC, Villasenor JM, Maule L, Lehmann L, 2021. Can social motivators improve handwashing behavior among children? Evidence from a cluster randomized trial of a school hygiene intervention in the Philippines. Am J Trop Med Hyg104: 756.
-
13.
Mani A, Mullainathan S, Shafir E, Zhao J, 2013. Poverty impedes cognitive function. Science 341: 976–80.
-
14.
Kahneman D, 2003. Maps of bounded rationality: psychology for behavioral economics. Am Econ Rev 93: 1449–1475.
-
15.
Spears D, 2011. Economic decision-making in poverty depletes behavioral control. BE J Econ Anal Policy 11.
-
16.
Dupas P, 2011. Health behavior in developing countries. Annu Rev Econ 3: 425–449.
-
17.
O’Donoghue T, Rabin M, 1999. Doing it now or later. Am Econ Rev 89: 103–124.
-
18.
Steinberg L, Graham S, O’Brien L, Woolard J, Cauffman E, Banich M, 2009. Age differences in future orientation and delay discounting. Child Dev 80: 28–44.
-
19.
Yurgelun-Todd D, 2007. Emotional and cognitive changes during adolescence. Curr Opin Neurobiol 17: 251–257.
-
20.
Hollands GJ, Shemilt I, Marteau TM, Jebb SA, Kelly MP, Nakamura R, Suhrcke M, Ogilvie D, 2013. Altering micro-environments to change population health behaviour: towards an evidence base for choice architecture interventions. BMC Public Health 13: 1218.
-
21.
Marteau TM, Hollands GJ, Fletcher PC, 2012. Changing human behavior to prevent disease: the importance of targeting automatic processes. Science 337: 1492–1495.
-
22.
Thaler RH, Sunstein CR, 2009. Nudge: Improving Decisions about Health, Wealth, and Happiness. London, UK: Penguin.
-
23.
Aunger R, Schmidt W-P, Ranpura A, Coombes Y, Maina PM, Matiko CN, Curtis V, 2010. Three kinds of psychological determinants for hand-washing behaviour in Kenya. Soc Sci Med 70: 383–391.
-
24.
Dreibelbis R, Kroeger A, Hossain K, Venkatesh M, Ram PK, 2016. Behavior change without behavior change communication: nudging handwashing among primary school students in Bangladesh. Int J Environ Res Public Health 13: 129.
-
25.
Grover E, Hossain MK, Uddin S, Venkatesh M, Ram PK, Dreibelbis R, 2018. Comparing the behavioural impact of a nudge‐based handwashing intervention to high‐intensity hygiene education: a cluster‐randomised trial in rural Bangladesh. Trop Med Int Health 23: 10–25.
-
26.
Blackwell C, Goya-Tocchetto D, Sturman Z, 2018. Nudges in the restroom: how hand-washing can be impacted by environmental cues. J Behav Econ Policy 2: 41–47.
-
27.
Naluonde T, Wakefield C, Markle L, Martin A, Tresphor C, Abdullah R, Larsen DA, 2019. A disruptive cue improves handwashing in school children in Zambia. Health Promot Int 34: e119–e28.
-
28.
Division TPaHDS , 2019. First Semester 2018 Official Poverty Statistics of the Philippines. Quezon City, Philippines: Philippine Statistics Authority.
-
29.
Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, Luby SP, 2013. The integrated behavioural model for water, sanitation, and hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health 13: 1015.
-
30.
Biran A, Schmidt W-P, 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: e145–e54.
-
31.
Judah G, Aunger R, Schmidt W-P, Michie S, Granger S, Curtis V, 2009. Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health 99: S405–S11.
-
32.
King D, Vlaev I, Everett-Thomas R, Fitzpatrick M, Darzi A, Birnbach DJ, 2016. “Priming” hand hygiene compliance in clinical environments. Health Psychol 35: 96.
-
33.
Botta RA, Dunker K, Fenson-Hood K, Maltarich S, McDonald L, 2008. Using a relevant threat, EPPM and interpersonal communication to change hand-washing behaviours on campus. J Commun Healthc 1: 373–381.
-
34.
Gomila R, 2021. Logistic or linear? Estimating causal effects of experimental treatments on binary outcomes using regression analysis. J Exp Psychol Gen 150: 700.
-
35.
McNeish D, 2014. Modelling sparsely clustered data: design-based, model-based, and single-level methods. Psychological Methods 19: 552–563.
-
36.
Clarke P, 2008. Theory and methods: when can group-level clustering be ignored? Multilevel models versus single-level models with sparse data. J Epidemiol Com Health 62: 752–758.
-
37.
Oshchepkov AY, Shirokanova A, 2020. Multilevel Modeling for Economists: Why, When and How. Moscow, Russia: Higher School of Economics Research Paper No. WP BRP, 233. Available at: https://wp.hse.ru/data/2020/06/29/1610354484/233EC2020.pdf.
| Past two years | Past Year | Past 30 Days | |
|---|---|---|---|
| Abstract Views | 1479 | 412 | 39 |
| Full Text Views | 203 | 117 | 1 |
| PDF Downloads | 162 | 75 | 0 |
Nudging Handwashing among Primary School Students in the Philippines: Evidence from a Cluster Randomized Trial
Haijing Crystal Huang
Haijing Crystal Huang
IDinsight, Technical Team Department, San Francisco, California;
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Nhu Le
Nhu Le
IDinsight, Southeast Asia Department, Philippines;
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Meghan Battle
Meghan Battle
IDinsight, Southeast Asia Department, Philippines;
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Jon Michael Villasenor
Jon Michael Villasenor
UNICEF Philippines Country Office WASH, Philippines
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Louise Maule
Louise Maule
UNICEF Philippines Country Office WASH, Philippines
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ABSTRACT.
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.
- Supplemental Materials (PDF 129 KB)
Author Notes
Financial support: Funding for the evaluation was provided by UNICEF Philippines and the USAID Water, Sanitation, and Hygiene Partnerships and Learning for Sustainability (WASHPALS) grant.
Authors’ addresses: Haijing Crystal Huang, IDinsight, Technical Team Department, San Francisco, CA, E-mail: crystalhuang33@gmail.com. Nhu Le and Meghan Battle, IDinsight, Southeast Asia Department, Philippines, E-mails: nhu.le@idinsight.org and meg.battle@idinsight.org. Jon Michael Villasenor and Louise Maule, UNICEF Philippines Country Office WASH, Philippines, E-mails: jmvillasenor@unicef.org and lmaule@unicef.org.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
Pogrebna G, Kharlamov A, 2020. The impact of cross-cultural differences in handwashing patterns on the COVID-19 outbreak magnitude. Regulation and Governance.
-
2.
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: 1372–1381.
-
3.
Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 2151–2161.
-
4.
Maleta KM, Manary MJ, 2019. WASH alone cannot prevent childhood linear growth faltering. Lancet Glob Health 7: e16–e7.
-
5.
Cumming O, Curtis V, 2018. Implications of WASH benefits trials for water and sanitation. Lancet Glob Health 6: e613–e4.
-
6.
UNICEF, 2019. Position Paper: Implications of Recent WASH and Nutrition Studies for WASH Policy and Practice 2019. Geneva, New York: UNICEF. Available at: https://www.who.int/water_sanitation_health/news-events/who-unicef-position-paper-on-wash-and-nutrition-studies-20191125.pdf.
-
7.
Chase C, Do Q-T, 2012. Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam. New York, NY: The World Bank.
-
8.
Rosen L, Manor O, Engelhard D, Brody D, Rosen B, Peleg H, Meir M, Zucker D, 2006. Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools. Prev Med 42: 27–32.
-
9.
Watson JA, Ensink JH, Ramos M, Benelli P, Holdsworth E, Dreibelbis R, Cumming O, 2017. Does targeting children with hygiene promotion messages work? The effect of handwashing promotion targeted at children, on diarrhoea, soil‐transmitted helminth infections and behaviour change, in low‐and middle‐income countries. Trop Med Int Health 22: 526–538.
-
10.
Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP, 2000. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 160: 1017–1021.
-
11.
Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW, 1990. Increasing ICU staff handwashing: effects of education and group feedback. Infect Control Hosp Epidemiol 11: 191–193.
-
12.
Jetha Q, Bisserbe C, McManus J, Waldroop D, Naliponguit EC, Villasenor JM, Maule L, Lehmann L, 2021. Can social motivators improve handwashing behavior among children? Evidence from a cluster randomized trial of a school hygiene intervention in the Philippines. Am J Trop Med Hyg104: 756.
-
13.
Mani A, Mullainathan S, Shafir E, Zhao J, 2013. Poverty impedes cognitive function. Science 341: 976–80.
-
14.
Kahneman D, 2003. Maps of bounded rationality: psychology for behavioral economics. Am Econ Rev 93: 1449–1475.
-
15.
Spears D, 2011. Economic decision-making in poverty depletes behavioral control. BE J Econ Anal Policy 11.
-
16.
Dupas P, 2011. Health behavior in developing countries. Annu Rev Econ 3: 425–449.
-
17.
O’Donoghue T, Rabin M, 1999. Doing it now or later. Am Econ Rev 89: 103–124.
-
18.
Steinberg L, Graham S, O’Brien L, Woolard J, Cauffman E, Banich M, 2009. Age differences in future orientation and delay discounting. Child Dev 80: 28–44.
-
19.
Yurgelun-Todd D, 2007. Emotional and cognitive changes during adolescence. Curr Opin Neurobiol 17: 251–257.
-
20.
Hollands GJ, Shemilt I, Marteau TM, Jebb SA, Kelly MP, Nakamura R, Suhrcke M, Ogilvie D, 2013. Altering micro-environments to change population health behaviour: towards an evidence base for choice architecture interventions. BMC Public Health 13: 1218.
-
21.
Marteau TM, Hollands GJ, Fletcher PC, 2012. Changing human behavior to prevent disease: the importance of targeting automatic processes. Science 337: 1492–1495.
-
22.
Thaler RH, Sunstein CR, 2009. Nudge: Improving Decisions about Health, Wealth, and Happiness. London, UK: Penguin.
-
23.
Aunger R, Schmidt W-P, Ranpura A, Coombes Y, Maina PM, Matiko CN, Curtis V, 2010. Three kinds of psychological determinants for hand-washing behaviour in Kenya. Soc Sci Med 70: 383–391.
-
24.
Dreibelbis R, Kroeger A, Hossain K, Venkatesh M, Ram PK, 2016. Behavior change without behavior change communication: nudging handwashing among primary school students in Bangladesh. Int J Environ Res Public Health 13: 129.
-
25.
Grover E, Hossain MK, Uddin S, Venkatesh M, Ram PK, Dreibelbis R, 2018. Comparing the behavioural impact of a nudge‐based handwashing intervention to high‐intensity hygiene education: a cluster‐randomised trial in rural Bangladesh. Trop Med Int Health 23: 10–25.
-
26.
Blackwell C, Goya-Tocchetto D, Sturman Z, 2018. Nudges in the restroom: how hand-washing can be impacted by environmental cues. J Behav Econ Policy 2: 41–47.
-
27.
Naluonde T, Wakefield C, Markle L, Martin A, Tresphor C, Abdullah R, Larsen DA, 2019. A disruptive cue improves handwashing in school children in Zambia. Health Promot Int 34: e119–e28.
-
28.
Division TPaHDS , 2019. First Semester 2018 Official Poverty Statistics of the Philippines. Quezon City, Philippines: Philippine Statistics Authority.
-
29.
Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, Luby SP, 2013. The integrated behavioural model for water, sanitation, and hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health 13: 1015.
-
30.
Biran A, Schmidt W-P, 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: e145–e54.
-
31.
Judah G, Aunger R, Schmidt W-P, Michie S, Granger S, Curtis V, 2009. Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health 99: S405–S11.
-
32.
King D, Vlaev I, Everett-Thomas R, Fitzpatrick M, Darzi A, Birnbach DJ, 2016. “Priming” hand hygiene compliance in clinical environments. Health Psychol 35: 96.
-
33.
Botta RA, Dunker K, Fenson-Hood K, Maltarich S, McDonald L, 2008. Using a relevant threat, EPPM and interpersonal communication to change hand-washing behaviours on campus. J Commun Healthc 1: 373–381.
-
34.
Gomila R, 2021. Logistic or linear? Estimating causal effects of experimental treatments on binary outcomes using regression analysis. J Exp Psychol Gen 150: 700.
-
35.
McNeish D, 2014. Modelling sparsely clustered data: design-based, model-based, and single-level methods. Psychological Methods 19: 552–563.
-
36.
Clarke P, 2008. Theory and methods: when can group-level clustering be ignored? Multilevel models versus single-level models with sparse data. J Epidemiol Com Health 62: 752–758.
-
37.
Oshchepkov AY, Shirokanova A, 2020. Multilevel Modeling for Economists: Why, When and How. Moscow, Russia: Higher School of Economics Research Paper No. WP BRP, 233. Available at: https://wp.hse.ru/data/2020/06/29/1610354484/233EC2020.pdf.
| Past two years | Past Year | Past 30 Days | |
|---|---|---|---|
| Abstract Views | 1479 | 412 | 39 |
| Full Text Views | 203 | 117 | 1 |
| PDF Downloads | 162 | 75 | 0 |