25102847
BACKGROUND	Diarrhoea and respiratory infections are the two biggest causes of child death globally .
BACKGROUND	Handwashing with soap could substantially reduce diarrhoea and respiratory infections , but prevalence of adequate handwashing is low .
BACKGROUND	We tested whether a scalable village-level intervention based on emotional drivers of behaviour , rather than knowledge , could improve handwashing behaviour in rural India .
METHODS	The study was done in Chittoor district in southern Andhra Pradesh , India , between May 24 , 2011 , and Sept 10 , 2012 .
METHODS	Eligible villages had a population of 700-2000 people , a state-run primary school for children aged 8-13 years , and a preschool for children younger than 5 years .
METHODS	14 villages ( clusters ) were selected , stratified by population size ( < 1200 vs > 1200 ) , and randomly assigned in a 1:1 ratio to intervention or control ( no intervention ) .
METHODS	Clusters were enrolled by the study manager .
METHODS	Random allocation was done by the study statistician using a random number generator .
METHODS	The intervention included community and school-based events incorporating an animated film , skits , and public pledging ceremonies .
METHODS	Outcomes were measured by direct observation in 20-25 households per village at baseline and at three follow-up visits ( 6 weeks , 6 months , and 12 months after the intervention ) .
METHODS	Observers had no connection with the intervention and observers and participant households were told that the study was about domestic water use to reduce the risk of bias .
METHODS	No other masking was possible .
METHODS	The primary outcome was the proportion of handwashing with soap at key events ( after defecation , after cleaning a child 's bottom , before food preparation , and before eating ) at all follow-up visits .
METHODS	The control villages received a shortened version of the intervention before the final follow-up round .
METHODS	Outcome data are presented as village-level means .
RESULTS	Handwashing with soap at key events was rare at baseline in both the intervention and control groups ( 1 % [ SD 1 ] vs 2 % [ 1 ] ) .
RESULTS	At 6 weeks ' follow-up , handwashing with soap at key events was more common in the intervention group than in the control group ( 19 % [ SD 21 ] vs 4 % [ 2 ] ; difference 15 % , p = 0005 ) .
RESULTS	At the 6-month follow-up visit , the proportion handwashing with soap was 37 % ( SD 7 ) in the intervention group versus 6 % ( 3 ) in the control group ( difference 31 % ; p = 002 ) .
RESULTS	At the 12-month follow-up visit , after the control villages had received the shortened intervention , the proportion handwashing with soap was 29 % ( SD 9 ) in the intervention group and 29 % ( 13 ) in the control group .
CONCLUSIONS	This study shows that substantial increases in handwashing with soap can be achieved using a scalable intervention based on emotional drivers .
BACKGROUND	Wellcome Trust , SHARE .

