Understanding the use of nudges in handwashing behavior change programs: Highlights from the 2019 UNC Water and Health Conference

Every year, the UNC Water and Health Conference convenes science, policy and implementation actors to discuss successes, challenges and next steps in water, sanitation and hygiene (WASH). With my work for the Global Handwashing Partnership, the conference not only provides an opportunity to meet with our partners face-to-face, but it also spurs new insights and evidence regarding WASH and other integrated issues.

In the past two decades, there has been a shift in activity from handwashing education to sustainable handwashing behavior change, which targets key motivators and triggers beyond traditional promotion and education activities. At this year’s UNC Water and Health Conference, the Global Handwashing Partnership and its partners convened a side session discussing the concept of nudges and how they can be integrated into future handwashing behavior change efforts. In this post, I describe our organized side session and highlight ways nudges can be used in practice.

What is a nudge?
Nudges are a strategic intervention that place emphasis on choice design.
Our session started off with a presentation from Dr. David Neal of Catalyst Behavioral Sciences and Duke University, who defined the differences between a nudge and a habit. Thaler & Sunstein (2008) define a nudge as “choice architecture that alters people’s behavior in a predictable way without forbidding any options.” The idea of nudges is based on the theory that behavior is not only based on conscious thoughts and decisions, but that choice architecture can unconsciously guide it. Nudges don’t rely on changing a person’s rational decision making, nor do they forbid a behavior or directly change incentives. Rather, nudges are a strategic intervention that place emphasis on choice design. A primary example of a nudge is placing a larger-sized recycling bin next to a smaller trash can. This choice architecture (the larger recycling bin) nudges individuals to recycle more.

According to Wood & Neal (2007), habits are defined as “learned dispositions to repeat past behavior triggered by features of context that have covaried frequently with behavior in the past.” In other words, habits are triggered by context and whether a person has performed that behavior in the past. Think about your morning routine. Let’s say you wake up, then immediately brush your teeth and wash your face before you do anything else. These are repeated behaviors that have led to lasting behavior change. These are habits.

While nudges and habits have overlapping constructs (e.g., they are both anchored in unconscious thinking), there are key differences to understand. For one, nudges are an intervention, whereas habits are a behavior. Nudges can be one-off or repeated and may not always lead to lasting behavior change. In contrast, habits must be repeated and should involve (at least somewhat) lasting behavior change. For nudges to create lasting change, they must obey the laws of habit formation.

How are nudges used in practice?

So, what if we want to use nudges to change habits? More specifically, how do we use nudges to change handwashing habits? While it seems like a simple concept, the frequency in which people should practice handwashing can lead to challenges in creating lasting behavior change. Because of this, many traditional approaches have failed in achieving and sustaining improved handwashing practices.

A simple nudge like installing mirrors over the handwashing stations led to a 62% increase in handwashing behavior.
Megan Williams from Splash provided examples where nudges have been tested and incorporated in their hygiene programming. For example, in Ethiopia, Splash implemented both drinking and handwashing stations into schools to promote improved WASH practices. The team implemented a series of nudges into the station designs after prototyping and testing. By using a bright orange color and providing a shallower basin, the team was able to distinguish the handwashing station from the drinking water station. This choice design allowed students to decipher which station was designated for handwashing specifically, thus prompting them to only use the orange stations to wash their hands. Additionally, a simple nudge like installing mirrors over the handwashing stations led to a 62% increase in handwashing behavior.

Dr. Robert Dreibelbis of the London School of Hygiene and Tropical Medicine then discussed how nudges have been used in efforts around the world. Nalounde et al. (2018), for example, used a school-randomized control trial to test “soap-on-a-rope.” The idea of this nudge stems from the classic “hall pass” concept in schools. In theory, by introducing the soap as an alternative to a hall pass, it prompts the students to believe that it should then be used after they use the toilet and when washing their hands. The researchers found that soap use was more than seven times more likely in intervention schools than control schools. Introducing this nudge interrupted habitual neurological patterns, which in turn affected and sustained behavior change.

Key takeaways
Nudges are a key intervention that can be used in future behavior change efforts to enact true habit formation.
Outside of our side session, the conference highlighted the need for more transformative WASH moving forward. Our sector must be more cognizant and intentional with our programming. Handwashing with soap is often a behavior done out of habit, rather than conscious choice. If we seek to guide people in developing sustained handwashing habits, nudges may be an important tool to encourage routine handwashing. While nudges can still be surrounded by much nuance, they are ultimately a key intervention that can be used in future behavior change efforts to enact true habit formation.


Photo credit: UNICEF Guinea

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