trial , the authors tested whether a scalable village-level
intervention based on emotional drivers of behavior, rather than
knowledge, could improve handwashing behaviour in rural India. Fourteen
villages were randomly assigned (1:1) to intervention (community and
school-based events incorporating an animated film, skits, and public
pledging ceremonies) or control (no intervention). Outcomes were
measured by direct observation in 20-25 households per village at
baseline and at three follow-up visits (6 weeks, 6 months, and 12 months
after the intervention). At 6 weeks, hand washing with soap at key
events was more common in the intervention group than in the control
group (19% vs 4%; P=0·005). At the 6-month follow-up
visit, the proportion washing hands with soap was 37% in the
intervention group versus 6% in the control group. At the
12-month follow-up visit, after the control villages had received the
shortened intervention, the proportion washing hands with soap was 29%
each in the intervention and control group. The authors concluded that
substantial increase in hand washing with soap can be achieved using a
scalable intervention based on emotional drivers.
This study has considerable relevance to the Indian
setting for three distinct reasons. First, although it is well known
that household hand hygiene practices are associated with reduction in
infection-related morbidity [2-6], it is a challenge to convey this
information to the target audience in an appealing fashion . Second,
merely conveying the message is inadequate unless it is backed by
actions to promote (and measure) the appropriate behavior [8-10]. Third,
the partial success observed in this trial suggests that such strategies
could be scaled-up to include a wider population, and could also be
extended to other health-care needs wherein a combination of education
with behavior change are required (for example, routine immunization,
infant nutrition, newborn care and rational antibiotic use).
This trial has included the methodological
refinements associated with high-quality randomized trials; this is
commendable considering the practical difficulties of stationing an
observer in the household for three hours each day. Sample size
calculation and statistical treatment of data appear appropriate.
However, there is no mention of an intention-to-treat analysis, and it
is unclear what was done for households where data could not be
collected. The steep rise in hand-washing observed between 6 weeks and 6
months in the intervention villages (19% to 37%) was because 4 villages
that initially showed no improvement appeared to improve later in the
trial. The reasons for the difference in behavior at 6 weeks, and the
delayed response are unclear, especially as 3 ‘better’ villages showed
no dramatic increase beyond 6 weeks. Village-wise data analysis also
suggests that there was a decline in hand-washing in one village.
Interestingly, at the 6-month observation point, 3 of the 7 control
villages showed greater hand-washing practices than the paired
intervention villages. This has also not been satisfactorily explained.
These observations suggest that pooling the data together masks the
differences at the ground level (and the reasons thereof). This has
important implications because it suggests that there are behavioral
differences at the individual household level, rather than village
level. Therefore a campaign targeting households rather than villages
could have greater efficacy.
The fact that even the small-scale intervention
provided to the control villages (after six months) resulted in
remarkable improvements, suggests that improvement (in both sets of
villages) may be influenced both by population contact with program
providers as well as the program content. This trial was conducted in a
typical rural setting within India, using local resources, tools and
language. Therefore, theoretically it should be easy to extend such a
strategy all over the country, and obtain similar impressive results.
However the key limitation could be the logistic (and financial)
challenges associated with an intensive campaign focused on one
health-related issue, and the measurement of its outcomes. In addition,
for all strategies implemented through a campaign mode approach, there
is the risk of community fatigue and waning of effect. This could be the
reason why the original intervention villages in this trial showed a
decline after 6 months. On the other hand, it is also possible that more
frequent targeting of the community with novel implementation methods
may be required to sustain community interest and participation. There
is also the practical challenge of whether the success observed in this
highly-controlled research-setting would be similar in a real-world
Another issue worth considering is that in this
trial, emotional drivers of behavior change were targeted, with an
intervention depicting positive behavior of a female fictional character
and negative male behavior. While this would be readily acceptable in
many rural and urban settings in India, it remains to be explored
whether such results could be obtained in male-dominated socio-cultural
settings within the country. It is also important to note that despite
statistically significant improvement in hand-washing, this occurred in
only about one-third of the target population. The majority showed no
change in practice. Whether this would be adequate to impact society
with clinically significant beneficial effects remains to be assessed.
Joseph L Mathew
Advanced Pediatrics Center,
PGIMER, Chandigarh, India.
Public Health and Policy Viewpoint
A complex solution for a simple problem is not the
The interventions in this trial appear to be driven
by technology, which may not always be available in low- and
middle-income countries (a specialized agency designed the campaign).
The interventions are resource-intensive, with up to 25 days being
required to deliver them. Further, the interventions do not appear to
have utilized the locally available human resources. It is not clear how
community-level workers, such as accredited social health activists
(ASHAs) and anganwadi workers (AWWs) have contributed to these efforts.
Moreover, these measures have been delivered as vertical interventions.
In the context of healthcare in low-resource
settings, it is necessary for any intervention to be based on the
existing health system. In fact, in any such setting, including India,
it is important to consider how any new intervention could be used for
boosting the ongoing efforts of the health system. It is also important
to use an integrated approach when delivering interventions utilizing
the locally available human resources, and simultaneously promoting
inter-sectoral coordination among local government bodies.
While the researchers in this trial claim to have
found ‘an implementable and scalable intervention’, the policy-makers
are likely to have a different opinion. This trial provides us with yet
another opportunity to explore the linkage between ‘academic research’
and possible ‘public health and policy application’. This situation
highlights the need for both stakeholders – academicians and public
health decision-makers – to be involved in the research from the very
outset, perhaps at the stage when the interventions are being designed.
This approach could ensure the optimal programmatic utilization of
It is good that researchers have started thinking
about improving behavior practices related to health care. However, it
should not tempt anyone to search for a complex and technology-driven
solution. Perhaps, there cannot be a complex solution for a simple
(The views expressed are personal).
Darpan Colony, RK Puri P.O.,
Gwalior-474011, MP, India
Over last few decades, hand washing has carved an
undeniable niche among various cost-effective and preventive strategies
in mitigating nosocomial or hospital acquired infections in different
healthcare settings. However, prevalence of hand washing with soap
during key events (after defecation, after cleaning a child’ bottom,
before food preparation and before eating) is dismally low at community
level worldwide, especially in low income countries. Results of present
study highlighted a marked increase in prevalence of hand washing with
soap (using direct structured observation) at any key event which peaked
at 6 months follow-up in intervention clusters. Though authors claimed
statistically significant results using summary measures at cluster
level, evidence provided is far from indisputable. Using summary
measures of hand-washing prevalence at 6 weeks in present study, the
mean difference between intervention and control groups is 15% with a
95% CI of -2.4% to 32.4%; this contradicts the statistical significance
(P=0.005) obtained by permutation test on standard t-test.
Similarly, authors claim to the contrary that there was significant
difference of hand-washing rates after potential fecal contact between
intervention (28%; SD 33%) and control clusters (7%; SD 8%) whereas
reported P value is 0.18 (not-significant). One fact notably
ignored by authors is dip in compliance rate to 29% (SD 9%) in
intervention cluster at 12 months of follow-up which has a 95%
confidence interval of 20.7% to 37.3%. Latter’s upper bound just barely
exceeded the 6-monthly hand washing rate of 37% suggesting that the
trend for fall in compliance cannot be ignored.
Spillover of beneficial intervention effects to
nonparticipants is a valuable public health benefit and should be part
of any program impact assessments. In the present study, authors have
described that enrolled villages were situated at least at a distance of
3 km, yet lack of any spill-over of this well-advertized behavioral
intervention in control clusters (with rates of 2%, 4% and 6% at
baseline, 6 weeks and 6 months, respectively) possibly hints at its
limited potential for widespread dissemination in real-world situation.
Furthermore, literature has labeled hand washing as ‘do it yourself’
vaccine which can interrupt transmission of various disease agents
causing diarrhea and respiratory infections. Rates less than 30% are
reported to be associated with high diarrhea-related child mortality in
literature . In this regard, achieving a highest hand washing
prevalence of 37% falling down to 29% over a period of one year
follow-up in present study suggests many bottlenecks in universalization
of optimal hand hygiene in community settings. A multi-pronged program
encompassing behavior changes strategies, knowledge driven interventions
and social marketing policies will be required to achieve desirable
public health outcomes .
Department of Pediatrics, PGIMER,
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