Promotional approaches can be effective in terms of handwashing with soap, latrine use, safe faeces disposal and open defecation. No one specific approach is most effective, however, several promotional elements were shown to induce behaviour change. Different barriers and facilitators which influence the implementation of promotional approaches should be taken into careful consideration when developing new policy, practice, or research projects regarding handwashing or sanitation.

The studies were conducted across 24 low- and middle-income countries. This included 28 studies from Sub-Sahara Africa, 26 from South Asia, 8 from South East Asia and Oceania and 2 from East Asia. We identified only 6 studies conducted in Central or Latin America. For most countries in Central or Latin America we identified few or no studies. It is also notable that evidence is mainly coming from 12 low-income countries (Bangladesh, Cambodia, Ethiopia, Haiti, Kenya, Malawi, Mali, Nepal, Nigeria (until 2007), Somalia, Tanzania, Thailand, Uganda, Vietnam (until 2008) and Zimbabwe) and 10 lower middle-income countries (China (until 2010), El Salvador, Guatemala, India, Nigeria (from 2007), Pakistan, Papua New Guinea, Peru (until 2008), South Africa, Thailand, Vietnam (from 2009) and Zambia) and is rather occasionally derived from 2 upper middle-income countries (China (from 2010) and Peru (from 2008)).

Promotional approaches targeting handwashing and sanitation behaviour are complex programmes based on several promotional elements, and adapted to the context of the environment where they are implemented. This could be confirmed in the studies included in this review. From the quantitative findings we conclude that there is not one promotional approach that is more effective than another.

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