Nudges can Pave the Way for Adopting Effective Hand Hygiene Behavior

Lack of proper hand hygiene puts people at risk of various hand borne diseases such as COVID-19, diarrhea, and other infections. Nudges that positively influence people in adopting thorough hand hygiene practices can prevent people from contracting such diseases.

Hand Hygiene in Times of COVID-19

The significance of hand hygiene has never assumed greater importance in recent times as it has in the past few months due to the menace of the global pandemic, COVID-19. Health experts, epidemiologists, and practitioners have been constantly recommending and urging the regular and thorough hand-washing using soap to eliminate the novel coronavirus, the source of COVID-19 disease. The soap dissolves the coat of the fat membrane of the virus, thus rendering it inactive and ineffective.

The Status in India

In India, the status of hand-washing leaves a lot to be desired. As per the National Sample Survey (NSS) 76th round report, 2019, a mere 35.8 percent of households in the country practice hand-washing with soap or detergent before a meal while 60 percent households wash hands only with water. The report further reveals that around 26 percent of Indians don’t wash their hands with soap or detergent after defecation.

The Nudge Theory

This situation calls for an urgent change in behavior of the people to vigorously adopt the practice of hand-washing using soap, especially in the face of COVID-19 threat alongside preventing other diseases such as diarrhea, pneumonia, and other infections. An effective mechanism in bringing about behavioral change can be by way of nudges that motivate people to make a beneficial choice without any duress. The origin of Nudge theory is in the 2008 book, “Nudge: Improving Decisions About Health, Wealth, and Happiness”, written by the American academics Richard H Thaler and Cass R Sunstein. The authors heavily draw from the work of Daniel Kahneman (awarded Nobel Memorial Prize in Economic Sciences in 2002) and Amos Tversky, who established the existence of cognitive biases.

Nudges for Hand Hygiene

Many organizations work on designing nudges that foster the adoption of appropriate hand-washing behavior. Seattle headquartered nonprofit, Splash, which works on safe water for children among other things across nations in Asia and Africa, uses nudges to promote hand hygiene. In Ethiopia, it installed mirrors over hand-washing basins in schools that led to an increase in hand-washing by 62 percent among school children. It helped the children differentiate hand-washing basins from drinking water stations by using orange color and shallower basin as part of changes during its prototyping.

Splash extended and further developed the approach to 24 schools in Kathmandu, Nepal. Apart from mirrors above hand-washing stations, it introduced signs with messages that evoked a feeling of revulsion or shared information and painted footsteps leading up to hand-washing stations. These nudges along with education and infrastructure enhanced the hand-washing rates from 9 percent to 65 percent.

The use of posters with hand-washing instructions has been found very effective to promote hand hygiene behavior. The Behavioural Insights Team (BIT) of the British Government, also known unofficially as the “Nudge Unit” undertook a study that compared the effectiveness of posters with hand-washing instructions from different nations and found that posters with little text and attractive graphics were most successful in encouraging proper hand-washing. Posters from Taiwan, Singapore, and the UK were found to be most effective.  Cues such as bright signage and prominent location also promote hand hygiene by attracting people’s attention. In an experiment done at a hospital in Demark, the use of hand sanitizer increased prominently from 3 percent to 7 percent when it was made available at a conspicuous location using a striking sign.

Various technological nudges for hand hygiene have also been evolved. Apple recently announced its latest watchOS7 update for its Apple Watch, which will help the users to wash their hands thoroughly to reduce the risk of contracting COVID-19. The Apple Watch will use a detector to identify the hand-washing movement and sound of water. Thereafter, the device will start a 20-second countdown timer to let a user know when the hands are properly cleaned. Atlanta based Clean Hands – Safe Hands has developed a product called Real-Time Voice Reminder™ that reminds clinicians to sanitize their hands through a voice-based message and claims that it has a high impact on behavior.

In another instance of the technological nudge, the Delhi Sikh Gurdwara Management Committee (DSGMC) recently announced that a social robot ‘Pepe’, developed collaboratively by researchers from the University of Glasgow and the Amrita Vishwa Vidyapeetham University in India will be used in schools operated by it to promote hand hygiene among the students. The speaking robots to be mounted above the hand-washing stations will interact with the students passing through the stations to encourage them to wash their hands properly.

Way Forward for India

In India, given the large population, it is imperative that different actors such as government organizations, corporate social responsibility (CSR) departments, foundations, NGOs, and research institutions should proactively explore and promote nudges, especially the inexpensive ones that positively influence the practice of proper hand hygiene among the citizens. An important step in this direction is the launch of a behavior change campaign called ‘Navigating the New Normal’ by the Government of India’s think tank NITI Aayog in association with different stakeholders. The campaign uses nudges along with other tools to encourage COVID-safe behavioral norms that also includes hand-washing.

Research has found that a nation-wide hand-washing behavior change program would provide a 92-fold return in India. If one also factors in COVID-19, the gains will be even higher. However, it also needs to be ensured that all citizens have access to effective hand-washing facilities. Currently, more than 50 million people in India lack access to these facilities according to a study done by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. So the way forward in maximizing and wider dissemination of the hand hygiene benefits is only possible through a combination of nudges and infrastructure development.  

(Views are personal)