Using Environmental Nudges to Improve Handwashing with Soap among School Children

"Evidence suggests that nudges can be effective at changing handwashing behaviour among school children."

Despite the well-known benefits of handwashing with soap - including to prevent COVID-19 and other communicable diseases - the practice is still challenging to sustain. (Estimated global rates of handwashing with soap after using the toilet are only 19%.) This guide is intended for programme staff involved in the design and implementation of a school-based hand hygiene intervention, particularly within the context of COVID-19-related school reopenings. It was created by the WASH in Schools (WinS) Network (Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, United Nations Children's Fund (UNICEF), Save the Children, Water Aid, and approximately 60 other organisations), which is a global interagency network of WinS practitioners.

Within schools, traditional handwashing promotion approaches focus on education-based messages that teach children about the importance of handwashing with soap and proper handwashing technique. However, evidence shows that perceived health benefits and knowledge are not strong determinants of handwashing behaviour change. The guide describes the COM-B behaviour change model and also looks at "the science behind nudges". Nudges work based on the understanding that our behaviour, particularly health-related behaviour, results from an automatic response to environmental and social cues that requires minimal conscious engagement. Thus, a good nudge should be easy, attractive, social, and timely, as well as inclusive of all users. Furthermore, messages (e.g., on a poster) should be kept clear and simple.

The focus of this guide is on a select number of nudge-based interventions - changes to the physical environment or objects in that environment that cue and trigger handwashing behaviours - that focus on using handwashing supplies and infrastructure placement and properties to cue and trigger handwashing among school-aged children. (Examples of nudges are described and pictured, such as the footpath nudge, soap on a rope, and germ pictures.) Naturally, schools need to provide and maintain access to handwashing infrastructure first and foremost, ensuring that opportunity for handwashing is met before or when implementing these nudges. Furthermore, the interventions described here should be viewed as an interim strategy; more detailed and comprehensive behaviour change strategies will be needed in order to ensure that handwashing behaviour is incorporated into existing school routines and translates into long-term habits.

Nudges alter the placement, presentation, and properties of handwashing with soap. This means that careful consideration must be given to where handwashing facilities are located in the schools, the design of these facilities, how students interact with these facilities, and how they are complemented by simple and clear messages. The resource provides guidance in areas of implementation, posing questions to prompt the reader. As noted here, among the steps in the process are observation, engaging with the intended audience (i.e., children) and other key stakeholders (e.g., teachers) to develop the nudges, and later pilot-testing them. Experimental and observational methods may be required in order to estimate the true effect on behavioural outcomes. The reader is advised that, to ensure nudges are well maintained, it may be necessary to adapt local monitoring tools.