Promoting Handwashing and Sanitation Behaviour Change in Low- and Middle-income Countries

"3ie systematic reviews appraise and synthesise the available high-quality evidence on the effectiveness of social and economic development interventions in low- and middle-income countries.....The aim for this systematic review was to show which promotional approaches might change handwashing and sanitation behaviour, and which implementation factors affect the success or failure of such promotional approaches."

This research group conducted a search to find both published and unpublished studies of promotional approaches to promote handwashing, latrine use, safe faeces disposal, and to discourage open defecation. Approaches included "community-based approaches, social marketing approaches, sanitation and hygiene messaging, or approaches based on elements of psychosocial theory." Forty-two studies - quantitative impact evaluations -  examined which promotional approach is better, whilst twenty-eight qualitative studies looked at factors that affect success or failure of the approaches.

Objectives included answering:

1. "What is the effectiveness of different approaches for promoting handwashing and sanitation behaviour change, in communities in low- and middle-income countries?
2. What factors influence the implementation of approaches to promote handwashing and sanitation behaviour change, in communities in low- and middle-income countries?"

Two reviewers used EPI-Reviewer software to screen studies for inclusion. "The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess the overall quality/certainty of evidence from quantitative studies included in this review. The qualitative studies were assessed using the CASP (Critical Appraisal Skills Program) checklist."  Four categories and results in each are described as:

1. "community-based approaches, a promotional approach where there is typically community involvement and engagement, and shared decision-making is part of the approach", primarily for sanitation interventions, in some cases combined with a handwashing with soap and/or water supply/water quality component. The most consistent results were obtained within this category, where at least a sanitation component was part of the programme; and this approach "may be effective in terms of handwashing with soap, and sanitation outcomes (latrine use, safe faeces disposal, and open defecation)....Influencing factors... are: a facilitator (e.g. health promoter, community leader) that is part of and representative of the community, the attitude of the implementer/facilitator, providing enough information, and creating a culture of cooperation. In addition, the gender of the facilitator seems to play an important role, since women prefer to discuss private issues with somebody of the same sex."
2. "social marketing approaches, a promotional approach combining enterprise approaches with demand stimulation, and assuming that people both want and are able to change their behaviour." These mainly show an effect on sanitation outcomes "when interventions have a combined handwashing and sanitation component" and may be limited by lack of sanitation loans, such that economically poor people without financial knowledge may not be reached without income generating possibilities.
3. "sanitation and hygiene messaging...,a predominantly directive educational approach, consisting mainly of one-way communication..." designed for increasing knowledge and/or skills. Effects did not appear to be sustainable in the long term. "In case of school level interventions with children, the duration of the intervention and involving the children’s parents seem to be positive influencing factors."
4. "elements of psychosocial theory, which are derived from a formal psychosocial theory and form the basis of the intervention." Using this approach in small-scale handwashing promotion interventions showed promise.  A promotional approach and use of interpersonal communication, including role play, were shown to be effective in certain circumstances.

Some communication methods included: soap opera formats, pamphlets, cards, discussion, transect walks, certificates for students, community events, teacher training, training of community "champions", songs, and plays.

Implications for policy and practice suggest that: "promotional approaches aimed at handwashing and sanitation behaviour change can be effective in terms of handwashing with soap, latrine use, safe faeces disposal and open defecation." In addition, "a combination of different promotional elements is probably the most effective strategy. The recognition of different barriers and facilitators that influence the implementation of these promotional approaches may have a triggering effect on its effectiveness."

Implications for research show "an urgent need to use a more uniform method of outcome measurement (type of outcomes, way of assessment, timing of assessment). This will facilitate making conclusions on the effects of promotional approaches in the future. In addition, it is important to further assess barriers and facilitators, identified in this review, alongside quantitative analyses of promotional approaches."