A cluster-randomised trial to evaluate an intervention to promote handwashing in rural Nigeria

Figures & data

Table 1. Respect People intervention components in the order of implementation

Activity	Description	Purpose
Community Meeting, (duration 1 hour), Day 1, morning.
Introductions and ‘What is respect’ discussion	Community members are asked to share their perspectives about how to show respect through a short interactive discussion	Establish that mutual respect is an important part of community life and that greetings are a part of respectful behaviour.
Disgust handshake	Audience shake hands with neighbour and then imagine they have just come from defecation.	Elicit disgust and fear of social rejection. Establish that it is disrespectful to shake hands if hands are not clean.
The 4 events	Members of the audience act out 4 key events for HWWS. Audience guesses what they are acting.	Reminder of key times of HWWS (before eating, after cleaning child before cooking and after defecation).
Voting and Mr Clean/Mr Dirty	Group of volunteers ‘vote’ by placing a stone in 1 of 2 buckets to indicate whether everyone in the community washes hands with soap at key times. Audience lines up behind Mr Clean or Mr Dirty posters to indicate who they want to be like. Votes from buckets are counted publicly.	Establish that washing hands with soap at key times is an injunctive norm. Establish that it is known that not everyone adheres to this norm Raise awareness that breaches of the injunctive norm may be noticed by others.
Film	A short, humorous film telling the story of a man who fails to wash hands after defecation, faces social exclusion as a result and finally is redeemed and socially accepted after washing hands with soap.	Establish that poor handwashing practice may be noticed and punished through social exclusion while good handwashing practice may be rewarded with social inclusion.
Compound Meetings (duration approx. 1 hour), day 1 afternoon and days 2 and 3
Introduction	Short, interactive discussion	Explain the purpose of the meeting, remind participants about the community meeting and/or summarise for those who did not attend.
Respect Code	Interactive discussion through which compound members develop a 3-point code of respect for their compound, of which 1 point is HWWS on key events. Write the code on a poster.	Establish HWWS as part of a repertoire of respectful, mannerly behaviour that is valued in the compound.
Pledging Ceremony	Adults and children separately take a public pledge to follow the respect code and to HWWS on key events. Adults also pledge to behave as role models for children.	Establish public commitment to HWWS.
Children’s Report Card	Each child is given a report card on which to record their handwashing practice, with help from an adult or older sibling, over the course of a week.	Encourage and incentivise repeat practice. Position handwashing as a behaviour that is noticed and observed.
Hardware Inspection	Householders show facilitators their current handwashing places and discuss things they might do to make HWWS easier for all.	Encourage householders to take steps to make HWWS easier and therefore more likely.
Door Stickers	A large sticker with the intervention logo and the words ‘We respect people’ placed in a prominent place on, or beside, the front door of each house.	Public display of support for the intervention and generate the impression that supporting the intervention, and therefore HWWS, is a social norm.

Figure 1. Flow diagram of the study.

Table 2. Respondent household characteristics (6 months post-intervention)

	No intervention (n^a = 90)	CLTS (n = 105)	CLTS+ (n = 105)
Household size (Standard Deviation)	6.2 (2.4)	6.4 (2.5)	6.0 (2.3)
Education care-giver, n (%)
Never attended school	7 (7.8)	11 (10.5)	9 (8.6)
Some primary school	14 (15.6)	16 (15.2)	27 (25.7)
Completed primary school	18 (20.0)	25 (23.8)	28 (26.7)
Some secondary school	25 (27.8)	27 (25.7)	24 (22.9)
Completed secondary school	22 (24.4)	18 (17.1)	11 (10.5)
Higher education or training	4 (4.4)	8 (7.6)	6 (5.7)
Education household head, %
Never attended school	6 (6.7)	9 (8.6)	5 (4.8)
Some primary school	5 (5.6)	6 (5.7)	13 (12.4)
Completed primary school	13 (14.4)	13 (12.4)	18 (17.1)
Some secondary school	19 (21.1)	21 (20.0)	16 (15.2)
Completed secondary school	25 (27.8)	24 (22.9)	36 (34.3)
Higher education or training	22 (24.4)	32 (30.5)	17 (16.2)
Main occupation farming, %	61 (67.8)	76 (72.4)	80 (76.2)
Owns agricultural land, %	87 (96.7)	99 (94.3)	104 (99.1)
Owns livestock, %	80 (88.9)	91 (86.7)	89 (84.8)
Owns a car, %	7 (7.8)	12 (11.4)	6 (5.7)
Owns a motorcycle, %	58 (64.4)	64 (61.0)	60 (57.1)

^an = sample size, i.e. the number of households in each arm.

Table 3. Effect of the intervention on handwashing

		n^a	Mean^b	SD^b	difference‡	95% CI lower	95% CI upper	P value
Handwashing with soap
All key events
	no intervention	820	4.8%	3.6%	1.8%	−0.9%	4.5%	0.2
	CLTS	701	2.9%	1.5%	ref	-	-	-
	CLTS+	799	5.1%	3.7%	2.4%	−0.4%	5.1%	0.096
After faecal contact
	no intervention	254	9.7%	7.5%	2.8%	−3.2%	8.8%	0.365
	CLTS	257	6.8%	3.4%	ref	-	-	-
	CLTS+	284	13.4%	9.8%	6.3%	−0.8%	13.4%	0.083
Before food contact
	no intervention	566	1.4%	1.7%	0.4%	−1.0%	1.9%	0.548
	CLTS	444	0.8%	1.2%	ref	-	-	-
	CLTS+	515	0.6%	1.1%	−0.1%	−1.2%	0.9%	0.81
Handwashing ± soap
All key events
	no intervention	820	39.0%	6.8%	5.9%	−1.7%	13.6%	0.13
	CLTS	701	33.2%	8.2%	Ref	-	-	-
	CLTS+	799	43.0%	12.5%	10.0%	−0.5%	20.4%	0.062
After faecal contact
	no intervention	254	42.0%	9.4%	2.3%	−8.3%	12.9%	0.671
	CLTS	257	38.7%	11.4%	Ref	-	-	-
	CLTS+	284	43.2%	18.2%	3.5%	−11.4%	18.5%	0.644
Before food contact
	no intervention	566	36.4%	7.0%	7.1%	0.0%	14.1%	0.05
	CLTS	444	30.4%	7.7%	Ref	-	-	-
	CLTS+	515	42.9%	13.4%	13.0%	2.4%	23.6%	0.017
SOAP use during other handwash
	no intervention	599	30.8%	17.8%	−10.8%	−27.2%	5.5%	0.194
	CLTS	461	41.6%	13.1%	Ref	-	-	-
	CLTS+	544	34.9%	12.9%	−6.7%	−19.7%	6.3%	0.312

^anumber of events observed; ^bmean and standard deviation (SD) of cluster level means;^cpercentage difference estimated using binomial regression (identity link, binomial distribution) with GEE/robust standard errors to adjust for clustering by village

Table 4. Effect of the intervention on knowledge and normative beliefs about handwashing

		Mean^a	SD^a	difference^b	95% CI lower	95% CI upper	P value
HWWS knowledge and beliefs
mentions HWWS before cooking
	no intervention (n = 90)	16.7%	9.2%	−9.0%	−19.5%	1.4%	0.09
	CLTS (n = 105)	25.7%	11.2%	ref	-	-	-
	CLTS+ (n = 105)	33.3%	9.4%	7.6%	−2.7%	17.9%	0.147
mentions HWWS before eating
	no intervention (n = 90)	56.7%	9.2%	6.2%	−4.4%	16.8%	0.252
	CLTS (n = 105)	50.5%	11.5%	ref	-	-	-
	CLTS+ (n = 105)	55.2%	11.4%	4.8%	−6.6%	16.1%	0.411
mentions HWWS after defecation
	no intervention (n = 90)	72.2%	14.2%	−4.9%	−18.3%	8.5%	0.471
	CLTS (n = 105)	77.1%	11.5%	ref	-	-	-
	CLTS+ (n = 105)	85.7%	4.6%	8.6%	−0.1%	17.3%	0.053
mentions HWWS after cleaning child
	no intervention (n = 90)	6.7%	4.2%	−1.9%	−6.7%	2.8%	0.432
	CLTS (n = 105)	8.6%	5.0%	ref	-	-	-
	CLTS+ (n = 105)	9.5%	6.5%	1.0%	−4.8%	6.7%	0.747
HWWS after defecation first mention
	no intervention (n = 90)	45.6%	7.8%	−2.1%	−11.1%	7.0%	0.654
	CLTS (n = 105)	47.6%	9.8%	ref	-	-	-
	CLTS+ (n = 105)	61.0%	11.8%	13.3%	2.5%	24.1%	0.015
believes that people commonly use soap after defecation in this village
	no intervention (n = 90)	51.1%	13.8%	4.4%	−9.8%	18.7%	0.54
	CLTS (n = 105)	46.7%	13.9%	ref	-	-	-
	CLTS+ (n = 105)	51.4%	9.2%	4.8%	−7.0%	16.5%	0.426
believes that people commonly use soap before eating in this village
	no intervention (n = 90)	40.0%	0.0%	−5.7%	−14.9%	3.4%	0.221
	CLTS (n = 105)	45.7%	13.0%	ref	-	-	-
	CLTS+ (n = 105)	50.5%	8.5%	4.8%	−6.2%	15.7%	0.393
believes that HWWS more in this village than others
	no intervention (n = 90)	76.7%	14.5%	−6.2%	−19.7%	7.3%	0.369
	CLTS (n = 105)	82.9%	11.5%	ref	-	-	-
	CLTS+ (n = 105)	81.0%	11.8%	−1.9%	−13.5%	9.7%	0.747

^amean and standard deviation (SD) of cluster-level means; ^bpercentage difference estimated using binomial regression (identity link, binomial distribution) with GEE/robust standard errors to adjust for clustering by village

Table 5. Water and sanitation hardware and markers of exposure to the intervention

		Mean^a	SD^b	difference^c	95% CI lower	95% CI upper	P value
Sanitation and handwashing hardware
House has latrine
	no intervention (n = 90)	46.7%	13.3%	−25.7%	−39.5%	−11.9%	<0.001
	CLTS (n = 105)	72.4%	13.6%	ref	-	-	-
	CLTS+ (n = 105)	73.3%	10.2%	1.0%	−11.0%	12.9%	0.876
Soap present at latrine§
	no intervention (n = 42)	6.7%	7.6%	−4.3%	−18.8%	10.2%	0.564
	CLTS (n = 76)	10.7%	18.5%	ref	-	-	-
	CLTS+ (n = 77)	9.9%	10.8%	−1.2%	−16.5%	14.2%	0.882
Water present at latrine§
	no intervention (n = 42)	4.9%	7.6%	−21.2%	−39.2%	−3.2%	0.021
	CLTS (n = 76)	25.9%	23.3%	ref	-	-	-
	CLTS+ (n = 77)	15.7%	16.8%	−9.9%	−30.7%	10.9%	0.351
Tippy-tap near latrine§
	no intervention (n = 42)	6.0%	10.3%	−4.0%	−14.6%	6.7%	0.465
	CLTS (n = 76)	8.6%	11.8%	ref	-	-	-
	CLTS+ (n = 77)	23.4%	18.3%	15.1%	−0.7%	31.0%	0.061
Markers of exposure to the intervention
heard of village event
	no intervention (n = 90)	75.6%	8.1%	10.8%	2.8%	18.8%	0.008
	CLTS (n = 105)	64.8%	7.4%	ref	-	-	-
	CLTS+ (n = 105)	88.6%	5.0%	23.8%	17.5%	30.1%	<0.001
present at village event
	no intervention (n = 90)	28.0%	7.5%	1.4%	−8.8%	11.7%	0.782
	CLTS (n = 105)	26.7%	12.2%	ref	-	-	-
	CLTS+ (n = 105)	66.7%	12.2%	40.0%	27.9%	52.1%	<0.001
heard of household visit
	no intervention (n = 90)	52.2%	13.6%	−9.7%	−21.5%	2.1%	0.107
	CLTS (n = 105)	61.9%	8.4%	ref	-	-	-
	CLTS+ (n = 105)	96.2%	3.6%	34.3%	27.9%	40.7%	<0.001
present at household visit
	no intervention	20.2%	14.5%	−8.4%	−22.7%	6.0%	0.254
	CLTS	28.6%	13.2%	ref	-	-	-
	CLTS+	81.0%	10.5%	52.4%	40.5%	64.2%	<0.001
house has campaign sticker
	no intervention (n = 90)	0.0%	0.0%	−4.8%	−11.8%	2.3%	0.184
	CLTS (n = 105)	4.8%	10.0%	ref	-	-	-
	CLTS+ (n = 105)	71.4%	15.3%	66.7%	53.8%	79.5%	<0.001

^amean and standard deviation (SD) of cluster-level means;^bpercentage difference estimated using binomial regression (identity link, binomial distribution) with GEE/robust standard errors to adjust for clustering by village; § responses restricted to households with latrine