Evaluating the Impact of Behavioral Nudges on Student Hand-washing in Elementary Schools in the Philippines

Study Overview
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Brief Summary
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This study evaluates the impact of school-based behavioral nudges installed in toilets and handwashing facilities on handwashing behavior among students in the Philippines. Nudges include: visible signage crafted to trigger behavioral motivators for handwashing; colorful pathway overlaid with footprints leading from the toilet to the handwashing station; sticker of a pair of eyes placed above the handwashing station; soap dish with an arrow beside it on the sink or counter to remind children to wash their hands with soap. The study's main hypothesis is that behavioral nudges will increase the percentage of students who wash their hands with water and soap after toilet use by 7 percentage points or more among schools where nudges were installed compared to control schools without nudges. The study is taking place in public primary schools in Zamboanga Del Norte, Philippines between October 2019 and May 2020.

Detailed Description
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The impact of the behavioral nudge intervention will be evaluated using a cluster randomized controlled trial (RCT). The investigators will randomly select 132 Department of Education (DepEd) schools across Zamboanga Del Norte province to comprise the study sample. 66 schools will be assigned to the treatment group, and 66 schools to the control group. Treatment schools will receive the behavioral nudge intervention, while control group will not. Both treatment and control schools will receive DepEd's national WASH in Schools (WinS) policy. WinS promotes correct hygiene and sanitation practices among school children and a clean environment in and around schools and includes initiatives related to infrastructure, knowledge, and behavior change, but does not include other programs with an explicit focus on handwashing promotion. Four months after installing nudges, enumerators will conduct structured observations in study schools, observing whether pupils wash their hands with soap, wash without soap, or do not wash, after they have used classroom toilets. This will be used to estimate the causal impact of the nudges intervention on rates of independent handwashing with water and soap after toilet use.

Official Title
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Evaluating the Impact of Behavioral Nudges on Student Independent Hand-washing Practices in Elementary Schools in the Philippines

Conditions
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Hand Disinfection

Intervention / Treatment
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* Behavioral: Behavioral nudges
* Behavioral: National WASH policy


Participation Criteria
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Eligibility Criteria
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Inclusion criteria: Water for handwashing is available at the school for at least certain days of the week The overall pupil to toilet ratio equals 100 or lower School has at least one individual handwashing station or group handwashing station School is situated in a district deemed safe by DepEd School does not have any planned WASH programming in the upcoming 2019-20 school year beyond standard WinS activities Exclusion Criteria: Water for handwashing is not available at the school for all days of the week The overall pupil to toilet ratio equals over 100 School does not have either an individual handwashing station nor a group handwashing station School is situated in a district deemed unsafe by DepEd School has at least one planned WASH programming in the upcoming 2019-20 school year beyond standard WinS activities

Ages Eligible for Study
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Minimum Age: 5 Years
Maximum Age: 12 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Behavioral nudges<br>Schools randomized to this arm will receive the behavioral nudges intervention and the Philippines Department of Education national WASH in Schools (WinS) policy. | Behavioral: Behavioral nudges<br>* Behavioral nudges include the following: Colorful pathway overlaid with footprints leading from the toilet to the handwashing station Rotating posters in toilet areas with messages targeting behavioral motivators for handwashing (disgust, social affiliation) Sticker of a pair of eyes placed above the handwashing station Soap dish with an arrow beside it on the sink or counter to remind children to wash their hands with soap<br>Behavioral: National WASH policy<br>* The Philippines' Department of Education National WASH in Schools (WinS) policy promotes correct hygiene and sanitation practices among school children and a clean environment in and around schools and includes initiatives related to infrastructure, knowledge, and behavior change, but does not include other programs with an explicit focus on handwashing promotion.<br>|
| Active Comparator: Control group<br>Schools in the control group will not receive handwashing nudges but will receive DepEd's national WASH in Schools (WinS) policy. | Behavioral: National WASH policy<br>* The Philippines' Department of Education National WASH in Schools (WinS) policy promotes correct hygiene and sanitation practices among school children and a clean environment in and around schools and includes initiatives related to infrastructure, knowledge, and behavior change, but does not include other programs with an explicit focus on handwashing promotion.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The probability that a student was observed to wash their hands with soap and water after toilet use | Unit of analysis: student | 4 months | 
| The probability that a student was observed to wash their hands with water after toilet use | Unit of analysis: student | 4 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The number of functioning handwashing facilities at the school | Unit of analysis: school | 4 months | 
| The number of functioning handwashing facilities with soap and water at the school | Unit of analysis: school | 4 months | 
| The probability that a toilet facility has a nearby functioning handwashing facility | Unit of analysis: toilet facility. A nearby handwashing facility means inside the classroom for toilet facilities located inside classrooms and within 10 meters of toilet facilities located outside classrooms. | 4 months | 
| The probability that a toilet facility has a nearby functioning handwashing facility with water and soap | Unit of analysis: toilet facility. A nearby handwashing facility means inside the classroom for toilet facilities located inside classrooms and within 10 meters of toilet facilities located outside classrooms. | 4 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Handwashing, Behavioral nudge, Contextual cue, Philippines, Health behavior, Nudge, Environmental cue, Behavior change