The Effect of Behaviour Change Interventions on Use of Public Handwashing Stations in Bangladesh

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Overview

As part of the COVID-19 response, BRAC has built 1000 public handwashing stations in several hundred villages in 20 sub-districts of Bangladesh. The investigators investigate the effects of two sets of behavioural interventions on use of the handwashing stations, compared to no additional interventions. The first set comprises passive nudges installed on and around the handwashing station, aimed at attracting people to the station. The second set comprises actively delivered higher-intensity interventions, including free soap offered as an incentive for using the handwashing station and a community board used to display social proof. This set of interventions aims to increase motivation to use the station.

As part of the COVID-19 response, BRAC, an international development organisation based in Bangladesh, has built 1000 public handwashing stations in several hundred villages in Dhaka, Khulna and Mymensingh divisions. The investigators investigate the effects of two sets of behavioural interventions on use of the handwashing stations, compared to no additional interventions. The first set of interventions, which do not require ongoing labour (hence termed 'low intensity'), involve the installation of various 'nudges' (e.g. mirrors and signposts) on the station and in the surrounding area; these interventions are designed to attract attention and guide people to the stations. The second set of interventions, which do require ongoing labour ('high intensity'), involve 'promoters' visiting the stations a few times a week for three weeks to hand out free bars of soap to station users, update a community board next to the station with cumulative usage numbers, and to encourage users to place comments or marks on the board as a form of social proof. Stations will be assigned to receive either the low intensity nudges, the high intensity intervention, or no additional intervention beyond BRAC's standard programming using a covariate adaptive randomisation process (with randomisation occurring at the village level to reduce spillover risk). The Investigators will measure use of the stations for one week prior to the implementation of the behavioural interventions, and then for a further six weeks. Station usage will be measured by a combination of structured observations and tally counters attached to the foot pedals that operate the station.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Interventions

Low Intensity NudgesBEHAVIORAL

A bundle of 'low-intensity' passive interventions, including: Large Mirrors \& hand-shaped sign posts pointing to the station

High Intensity ActivitiesBEHAVIORAL

A bundle of 'high-intensity' active interventions delivered for three weeks, including: Free soap and free facemasks for handwashing station users, a community message board \& general encouragement

BRAC's business-as-usualBEHAVIORAL

A set of community activities to increase awareness of public handwashing stations and the need to use them. This includes in-person group sessions demonstrating hand hygiene as well as stickers and posters placed in the community to alert people to the handwashing stations.

Eligibility

Sex: ALLHealthy volunteers:

Medical Language ↔ Plain English

Note: the sample consists of villages that have received at least one public handwashing station from BRAC, rather than human participants, though the investigators are measuring the use of the stations by human participants. The initial sample of villages has been chosen from a set of 1,899 villages identified by BRAC as being eligible for this project based on criteria related to COVID-19 cases, existing BRAC programs and village characteristics. The villages are spread across 3 of Bangladesh's 8 divisions, 8 of its 64 districts, and 20 of its 492 subdistricts ('upazilas'). While most of the 'villages' are located in rural parts of Bangladesh, roughly 15 percent are better characterised as wards or towns within urban and peri-urban municipalities. Inclusion Criteria: Villages identified by BRAC as being eligible for this based on: * COVID-19 cases * Existing BRAC programs * village characteristics * viable location for a handwashing station (space/water source) * local community members willing to 'sponsor' and maintain handwashing station Exclusion Criteria: * Lack of viable location for a handwashing station. * Villages that received handwashing stations as part of the pilot phase * Villages randomly selected in a related impact evaluation measuring the impact of the stations themselves

Outcomes

Primary Outcomes

Average handwashing station soap pedal presses per day (in weeks 1 to 3)

The investigators will use the number of times the soap pedals on the handwashing stations are pressed as a proxy measure of the frequency of use of the handwashing station for handwashing with soap. This data will be collected via mechanical tally counters ('clickers') connected to the soap pedals such that their count increments when the soap pedal is pressed. The clicker counts will be recorded at 4 points each day for 5 days per week. The investigators will use this information to infer the average number of soap pedal presses per day in the three weeks after the T2 and T3 interventions are first installed or delivered. The investigators will also attempt to translate this outcome to an estimate of the number of times the handwashing station was used per day, by correlating soap pedal presses with counts of handwashing station users gathered via structured observations in 3 half-hour periods each day.

Time frame: At the end of 3 weeks post-implementation

Secondary Outcomes

Average handwashing station soap pedal presses per day (in weeks 4 to 6)

This outcome will be measured identically to the primary outcome, but measures usage over the slightly longer term (the second three-week period after the T2 and T3 interventions are first installed or delivered). The investigators will also attempt to translate this outcome to an estimate of the number of times the handwashing station was used per day, by correlating soap pedal presses with counts of handwashing station users gathered via structured observations in 3 half-hour periods each day.

Time frame: At the end of 6 weeks post-intervention