Diarrhoeal diseases are very common causes of death in low and middle-income countries. The aim for this systematic review was to show which promotional approaches might change handwashing and sanitation behaviour, and which implementation factors affect the success or failure of such promotional approaches.

For community-based approaches, involvement of the community, enthusiasm of community leaders, having a sense of ownership, the implementer being part of the community, gender of the implementer, trust, income generating activities, clear communication and developing a culture of cooperation facilitated the implementation. For sanitation and hygiene messaging, barriers identified were (SMS) messages that were too long or culturally inappropriate, passive teaching methods in schools, the need for longer intervention periods and frequent reminders with children, overlap of school level intervention with interventions in the community, and lack of interest and involvement from the family in case of a school intervention, as well as illiteracy. For the social marketing approach barriers were mainly about the use of sanitation loans (lack of communication to latrine business owners about which area to cover, sanitation loans not reaching poor people, attitude of the loan officers, interest rate of loans, loan processing times), lack of financial knowledge and poverty.

An important implication is that there is a need for a more uniform method of measuring and reporting on handwashing, latrine use, safe faeces disposal, and open defecation. This will facilitate making conclusions on the effects of promotional approaches in the future. It is also important to further assess barriers and facilitators, identified in this review, when implementing promotional approaches.

International Initiative for Impact Evaluation (3ie) have also produced a related Systematic Review Brief from their findings: Handwashing and Sanitation Behaviour Change in WASH Interventions