Effects of complexity of handwashing instructions on handwashing procedure replication in low-income urban slums in Bangladesh: a randomized non-inferiority field trial

Handwashing instructions vary in complexity, with some recommending multiple steps. To assess whether complex handwashing instructions changed handwashing procedure replication, we conducted a randomized non-inferiority trial in a low-income area, Dhaka. We randomly assigned mothers and children aged 5-10 years to one of three handwashing instruction sets: simple (N = 85 mothers/134 children), moderate (N = 75 mothers/148 children), or complex (84 mothers/147 children). Simple instructions had three steps: wet, lather, and rinse hands, and moderate included the simple instructions plus steps to scrub palms, backs of hands, and dry hands in the air. Complex instructions included moderate instructions plus steps to scrub between fingers, under nails, and lather for 20 s. After baseline, cue cards were used to promote handwashing instructions, and adherence after 2 weeks of interventions was evaluated. Compliance with handwashing procedure replication to all instructions in simple, moderate, and complex increased after the intervention among mothers and children. Compliance to all instructions in the simple group was higher in the simple group (100%) compared to all instructions in moderate (47%) and complex instruction groups (38%). Simple handwashing steps are easier to remember for long time periods compared to complex steps.