Kazuhiko Kotani  ( Department of clinical laboratory Medicine, Jichi Medical University, Shimotsuke, Japan. )

Dear Madam, We read with great interest the Almas study concerning the knowledge and practice of hand-washing among mothers with children in a rural community in Sialkot District.¹ Good hand hygiene is known to be effective for preventing infectious diseases and related mortalities in children. ¹ A counterplan, such as hand-washing promotion, for children is required in schools in rural communities and developed countries where the hygiene level is not very high. ² However, worldwide, there have been limited data concerning the promotion of hand hygiene, particularly in rural schools; therefore, the Almas study¹ provided us with valuable information. To promote hand hygiene, we would like to add some further comments concerning approaches to hand-washing behaviours.

Several approaches² to fostering hand-washing behaviours have been attempted, including using behaviour science theories, social cognition models, or knowledge and practice as in the Almas study. ¹ Besides these approaches, the application of nudges, a new approach to behaviour changes, has recently gained great attention. Nudges promote the enaction of behaviours automatically rather than by conscious decision, and environmental nudges trigger targeted behaviours. In one interesting study, a cluster-randomized trial showed the effects of hand-washing intervention based on the nudge concept in rural schools of Bangladesh. ³ Under the concept, the paved pathways, latrines connected to hand-washing stations with soap, and shoeprints and handprints on infrastructure were used in that study. ³ The nudge intervention consequently improved hand-washing behaviours. ³

Education programmes and campaigns focussed on the knowledge and practices of mothers with children, as described by Almas, ¹ are one such way of promoting hand-washing behaviours. However, as human behaviours generally consist of complex features, the combination of several approaches, including environmental nudges, may be worth consideration. The most appropriate plans can also differ among communities. ² Should approaches involving nudges be considered for the rural community in Sialkot District? Further studies concerning the promotion of hand-washing behaviours in children are expected from Pakistan and other countries.

Disclaimer: None.

Conflicts of interest: None.

Funding disclosure: None.

The authors of the study on which comments are presented, have not responded to the critique.

References

1.       Almas S, Kawish AB, Butt TM, Akber S. Knowledge and practices regarding hand-washing among mothers of children less than five years of age in rural areas of District Sialkot. J Pak Med Assoc. 2021; 71: 105-9.

2.       Tao SY, Cheng YL, Lu Y, Hu YH, Chen DF. Handwashing behaviour among Chinese adults: a cross-sectional study in five provinces. Public Health. 2013; 127: 620-8.

3.       Grover E, Hossain MK, Uddin S, Venkatesh M, Ram PK, Dreibelbis R. Comparing the behavioural impact of a nudge-based handwashing intervention to high-intensity hygiene education: a clusterrandomised trial in rural Bangladesh. Trop Med Int Health. 2018; 23: 10-25.