Promoting handwashing and sanitation behaviour change in low- and middle-income countries: a mixed-method systematic review

Publication Details

Buck, ED, Remoortel, HV, Hannes, K, Govender, T, Naidoo, S, Avau, B, Veegaete, AV, Musekiwa, A, Lutje, V, Cargo, M, Mosler, HJ, Vandekerckhove, P and Young T, 2017. Promoting handwashing and sanitation behaviour change in low- and middle-income countries: a mixed-method systematic review. 3ie Systematic Review 36. London: International Initiative for Impact Evaluation (3ie).

Link to Source
Emmy De Buck, Hans Van Remoortel, Karin Hannes, Thashlin Govender, Selvan Naidoo, Bert Avau, Axel Vande veegaete, Alfred Musekiwa, Vittoria Lutje, Margaret Cargo, Hans-Joachim Mosler, Philippe Vandekerckhove, Taryn Young
East Asia and Pacific (includes South East Asia), South Asia, Sub-Saharan Africa, Latin America and the Caribbean
Water and Sanitation, Health Nutrition and Population
Preventive Health and Health Behavior, Water Supply and Sanitation Reform, Urban Water and Sanitation, Rural Water and Sanitation
Equity Focus
Review Type
Effectiveness review

Main findings

Headline Findings: a summary statement

Promotional approaches can be effective in terms of handwashing with soap, latrine use, safe faeces disposal and open defecation. No one specific approach is most effective, however several promotional elements were shown to induce behaviour change. Different barriers and facilitators which influence the implementation of promotional approaches should be taken into careful consideration when developing new policy, practice, or research projects regarding handwashing or sanitation. 

Evidence Base

The geographic distribution of studies is uneven. The studies were conducted across 24 low- and middle-income countries. This included 28 studies from Sub-Sahara Africa, 26 from South Asia, 8 from South East Asia and Oceania and 2 from East Asia. We identified only 6 studies conducted in Central or Latin America. For most countries in Central or Latin America we identified few or no studies. It is also notable that evidence is mainly coming from 12 low-income countries (Bangladesh, Cambodia, Ethiopia, Haiti, Kenya, Malawi, Mali, Nepal, Nigeria (until 2007), Somalia, Tanzania, Thailand, Uganda, Vietnam (until 2008) and Zimbabwe) and 10 lower middle-income countries (China (until 2010), El Salvador, Guatemala, India, Nigeria (from 2007), Pakistan, Papua New Guinea, Peru (until 2008), South Africa, Thailand, Vietnam (from 2009) and Zambia) and is rather occasionally derived from 2 upper middle-income countries (China (from 2010) and Peru (from 2008)).

Most (68%) of the studies were performed in a rural setting (48 studies), 13% in an urban setting (9 studies), 10% in an informal-rural setting (7 studies) and 3% in both a rural and urban setting (2 studies). Information about the setting was missing in 4 studies (6%). In 78.5% of the included studies, handwashing and sanitation promotional approaches were targeted at a household level (27.1%), a community level (24.3%), a school level (15.7%) or a village level (11.4%).

The intervention exists of a promotional approach on the one hand, and a WASH component on the other hand. The majority of interventions (40.5%) used a community-based approach to promote sanitation and/or handwashing behaviour (31 studies, 34 interventions). Most of these interventions focused on sanitation (15 interventions) or contained multiple WASH components (14 interventions). In 12 interventions (9 studies), sanitation and/or handwashing behaviour was promoted via the social marketing approach. Most of these interventions were specifically focused on handwashing (5 interventions) or sanitation (4 interventions). Twenty-four interventions (20 studies) used sanitation and hygiene messaging to promote handwashing and/or sanitation behaviour change. Almost half of these interventions (42%) were focused on hygiene (including handwashing). Finally, interventions that were based on elements of psychosocial theory were identified in 14 interventions (10 studies). Almost all of these interventions (86%) were focused on hygiene.

Among the 42 quantitative studies, we identified 34 studies comparing a specific promotional approach versus no intervention. Of these, 9 studies described programs that included (non-)financial incentives, including one study that compared a community-based intervention with and without use of subsidies (i.e. latrine vouchers).

In addition to the 34 studies, 7 studies only looked at the relative effectiveness of a promotional approach versus another promotional approach, and 1 study compared programmes with a similar promotional approach (i.e. sanitation and hygiene messaging) but with different communication channels (interpersonal + mass media communication versus mass media only).

Implications for policy and practice

Promotional approaches targeting handwashing and sanitation behaviour are complex programmes based on several promotional elements, and adapted to the context of the environment where they are implemented. This could be confirmed in the studies included in this review. From the quantitative findings we conclude that there is not one promotional approach that is more effective than another. In other words, one size does not fit all.

However, several effective elements of behaviour promotion could be identified, including:

  1. involving the community in the context of sanitation programmes (i.e. community-based approach: involving the community in the different stages of the design and implementation of the intervention, therefore resulting in tangible actions taken by community members),
  2. social marketing elements in the context of sanitation programmes (i.e. determining people-centred needs, stimulating demand for handwashing and sanitation options, delivering desired satisfactions more effectively and efficiently than competitors, working with local builders and other entrepreneurs, considering consumer preferences and desires),
  3. adding elements derived from psychosocial theory to the promotional approach in the context of a handwashing intervention (i.e. using psychosocial theory, social cognitive elements or theoretical elements of behaviour change to design the intervention), and
  4. use of interpersonal communication, as part of the communication strategy. The review of studies that used sanitation and hygiene messaging, with emphasis on one-way communication, revealed that it seems not to be sufficient to achieve long-term effect on handwashing and sanitation (latrine use, safe faeces disposal, open defecation).

Concerning the use of incentives as part of the promotional approach, it is difficult to generalize findings, since we only found a limited number of studies that used a wide range of incentives (from soap bars, to food over subsidies). One study reported promising results when using subsidies as part of the community-based approach, but more research on the use of subsidies and incentives would be valuable.

It should be noted that evidence concerning the use of elements derived from psychosocial theory was only found in small-scale studies implementing a handwashing programme, nevertheless such promotional elements could be added to a broader programme. Determining which theory-based elements are relevant in a certain context should be part of an assessment/pilot phase. Therefore, a more in-depth formative research during the assessment phase, leading to the right selection of promotional elements, seems to be a critical step for programmes aiming at behaviour change for sanitation and handwashing.

Implications for further research

An important implication of our work is that there is an urgent need to use a more uniform method of outcome measurement (type of outcomes, way of assessment, timing of assessment). This will facilitate making conclusions on the effects of promotional approaches in the future. In addition, it is important to further assess barriers and facilitators, identified in this review, alongside quantitative analyses of promotional approaches. Finally, well-conducted experimental studies on the effectiveness of handwashing and sanitation promotional approaches are still lacking, especially for the social marketing approaches, sanitation and hygiene messaging and interventions with elements of psychosocial theory.


Water and sanitation are at the very core of sustainable development, critical to the survival of people and the planet. The Sustainable Development Goal 6 (that is, ‘ensure availability and sustainable management of water and sanitation for all’) addresses the issues relating to drinking water, sanitation and hygiene. It is unclear which Water, Sanitation and Hygiene (WASH) promotional approach is the most effective for sanitation and hygiene behaviour change, and other outcomes leading to behaviour change (for example learning outcomes) or longer term outcomes that follow from behaviour change (for example, mortality, morbidity).

Research objectives

The objective of this systematic review is to show which promotional approaches are effective in changing handwashing and sanitation behaviour, and which implementation factors affect the success or failure of such interventions. This goal is achieved by answering two different review questions.

Question 1: What is the effectiveness of different approaches for promoting handwashing and sanitation behaviour change, in communities in low- and middle-income countries?

Question 2: What factors influence the implementation of approaches to promote handwashing and sanitation behaviour change, in communities in low- and middle-income countries?


A comprehensive search was conducted to identify both published and unpublished studies. Using a sensitive search strategy, we searched a range of databases from 1980 to March 2016, including Medline (PubMed), Cochrane CENTRAL and Social Sciences citation index (SSCI, Web of Science). To find unpublished material and relevant programme documents, we contacted various research groups and organizations and/or checked the relevant websites. Participants of interest included both children and adults from low- and middle-income countries (LMICs), as defined by the World Bank, at the time the intervention was implemented. Studies performed at an individual, household, school or community level were included, whereas studies conducted in institutional settings (e.g. hospitals) were excluded. The following promotional approaches or elements to promote handwashing, latrine use, safe faeces disposal, and to discourage open defecation (primary outcomes), were included: community-based approaches, social marketing approaches, sanitation and hygiene messaging and elements of psychosocial theory.

For Question 1 (effectiveness of promotional approaches), we included impact evaluations using an experimental, quasi-experimental design and observational analytical studies. To answer Question 2 (implementation aspects), all qualitative study designs addressing factors influencing implementation of the promotional approaches were considered for inclusion. This included, for example, grounded theory, case studies, phenomenological studies, ethnographic research, action research and thematic approaches to qualitative data analysis.

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess the overall quality/certainty of evidence from quantitative studies included in this review. The qualitative studies were assessed using the CASP (Critical Appraisal Skills Program) checklist. Evidence relating to Question 1 (effectiveness of promotional approaches) was synthesized in a quantitative way (meta-analysis), where possible.

Source link


Photo © World Bank

Scroll to Top