Cracking the Nut: Stimulating Behavioral Change in Water, Sanitation & Hygiene
It’s been two months since the year 2020 has started. Often, many of us get into making the New Year’s resolutions and trying to put them into practice – to read, to exercise, to visit friends and relatives…. Yet, truth be told, year after year, almost everyone fails to complete them.
Sticking to an action and developing it as a habit is all about behaviors or mindsets – our thought process. That’s why changing behavior is challenging with few equals. It can be difficult to try new things or stop certain unhelpful and limiting habits. We know this from practice – we failed, for example, in Benin to change behaviors of people in water, sanitation and hygiene.
Several independent studies such as in India, Ethiopia, Bolivia, as well as our own studies in Benin and Nepal have shown that improved water quality is enhanced by a certain technology (filter, chlorine, etc.), but it can also be the proper installation of a system (without treatment) that does provide clean and safe water. We don’t have to do a lot of analysis to know the answer: the problem lies in inadequate practices on hygiene, water transport and storage.
We have learnt that what holds the key for success is behavioral change – from handwashing to the use of toilets or water treatment and storage. A behavior change occurs not because a person is told or educated how to manage water and sanitation. A successful approach considers many psychological and social behavioral factors. For example, water, sanitation and hygiene interventions need to be embedded into schools, households and communities in which people spend their time and live their lives. It also considers economic factors – the impact of inadequate water and sanitation services falls primarily on the poor.
In this blog post, we move from the why to the how of behavioral change in water and sanitation, and present practical ways of addressing the issue of motivations. We learnt from our experiences that conventional hygiene awareness raising, like the one in Benin, hasn’t led to convincing results in terms of behavior change. Even though people know what they should do, they don’t do it.
What else to do? We searched for and used a scientifically tested psycho-social model called the Risks, Attitudes, Norms, Abilities, and Self-regulation approach – in short RANAS. In collaboration with its founder and creator, we simplified and contextualized it to the realities of different countries. Put simply, we identify the decisive behavioral factors and develop hygiene interventions to trigger them.
Understanding behavior
If we’re living in or traveling to a country with low level of water and sanitation services, it’s likely that we’ve asked ourselves the question: ‘am I at risk of contracting diarrhea’? This’s a risk factor of perceived vulnerability. Depending on the person, this can be the starting point for taking an action but doesn’t necessarily be enough. We may have heard about the health effects of drinking unsafe water, but we may not feel personally at risk or don’t perceive diarrhea as very severe for our daily life.
Imagine a restaurant where the handwashing station is outside of the toilet, clearly visible to customers from the main restaurant hall. It’s highly likely that more people will wash their hands than if the handwashing tap is located inside a toilet cabin. To state the obvious, we don’t exist in isolation from surrounding informal rules and social norms. Psychosocial factors steer our behavior, and social norms shape and sometimes reinforce the way we act. We’re somehow affected if our relatives wash their hands, or our parents or schoolteachers encourage us to wash our hands.
That’s why we need to understand well the behavioral factors and identify the decisive ones. For some people, what decisively makes the difference is their skills and knowledge to perform the behavior – for example, if we know the different steps to wash our hands correctly.
For others, the confidence in their ability to deal with possible barriers, to continue and to resume is the most critical in keeping up a good behavior. A simple example is if we feel confident that we’ll start washing our hands again when we’re at home and have access to water and soap. Simply stated, commitment and remembering can be important determinants.
How to actually change behaviors?
Let’s travel to Mozambique. Like in other countries, community-led total sanitation campaigns are questioned – that is, people doubt their relevance or ignore the messages. Certainly, this puts sustainability of open defecation free status in doubt. But the question is: what factors can influence the behaviors of communities in the use and maintenance of latrines?
As we said above, complex networks of social norms are often at play. It’s crucial that we understand how social norms work and we’re able to navigate them carefully for effectively influencing positive changes. In the RANAS study in Mozambique, the social norms and self-regulation factors have been identified as decisive ones, therefore hygiene interventions need to address those factors. That’s what happened in Mozambique – supporting sustained behavioral change by engaging families to publicly commit to use and maintain properly their latrine.
Two months later, the communities in Mozambique were visited again to identify and evaluate the families that have well maintained their latrine. Families with clean latrines were ‘awarded’ with a colored flag which most people fixed near their latrine. A notable social impact in the community has been observed – other community members started to repair or rebuild and well maintain their latrines to receive their own flag in order to be ‘at the same level’ as the other families. This was done during a second visit to the community six months later. Families that still maintained well their latrine and/or now maintained well their latrine were rewarded with a colored flag. Those families that did not fulfill the requirement anymore, the flag was withdrawn.
What is the result of this new post-Community Led Total Sanitation (CLTS) intervention? People maintaining well their latrine increased to 47% compared to 27% of people that have participated to a traditional CLTS intervention. This showed that the public commitment combined with the public reward (flag) worked well as an incentive for behavioral change. Even after a year, more than a quarter of the families had latrines in good condition. There was no significant difference between the families with flags and other families in the communities, showing that the flag worked as an incentive for behavioral change.
Let’s move to Mali, another Sub-Saharan African country. There we achieved very encouraging results for handwashing with soap. Today, 48% of people are washing their hands compared to 15% before the hygiene interventions. How has this been achieved?
Based on a thorough RANAs study, we developed a combination of interventions addressing the factors of social norms and autoregulation.
Here’s how it happened. The tippy-tap hand-washing stations have been constructed and located in visible areas. There was a reason for doing this – neighbors can see if people coming from the toilets wash their hands or not. Also, communities appreciated much a theater play in which a scene shows people washing their hands as being the most popular ones. It was simple but a powerful way that really stimulated community members to take actions of handwashing before handling food, like a poster hanging on the walls near the cooking areas showing the village chief washing his hands.
Moving from Africa to Latin America, the case from Bolivia demonstrates stimulating behavioral change in the separation and recycling behavior of households. For Bolivians, a critical constraint was the fact that water and sanitation issues were both a development and a political problem, and no longer just a public health crisis. Population growth in urban and peri urban areas has not been accompanied by an improvement in wastewater treatment or solid waste management infrastructure and services. In fact, infrastructure and related services are very often absent or in poor technical and management conditions, causing soil and water pollution and health problems.
The focus of our work in Bolivia was to trigger behavioral factors for waste separation and recycling by designing an effective sensitization campaign. What caught our attention was how the doers – those who really changed their behavior – were aware that how they acted affected the quality of services from the municipality.
We also found out that participation of those who were perceived as ‘respected’ in the communities encouraged the change in behavior of others (i.e. norm). Those who changed their behavior also felt more confident to maintain their behavior and it was less time consuming to do it (i.e. ability) and more committed to do it (i.e. self-regulation).
All the above were the result of a series of facilitation done by the initiative. An interesting example is the formation of brigades with young leaders who do environmental social action. Brigades are trained in environmental leadership, separation, exploitation and gender equity. Complementing the brigades were also environmental barter fairs that work in waste-for-resource activities, focusing on bartering of recyclable materials, training using puppets and other games to create objects, articles and tools for everyday use. Calendars were also introduced as easy-to-use information on separation that were used as memory aid to mark different pick-up days. Recognizing the importance of norms, the initiative in Bolivia also used famous people to encourage people to separate their solid waste.
With the combination of the above interventions, now 53% of the population in the targeted middle-sized cities now separate and recycle their solid waste compared to 17% before the intervention started.
Now what?
We start with the seemingly obvious but ignored fact. Different initiatives in water and sanitation too often see individuals as ‘autonomous and fully rational agents’ rather than understanding the complex dynamics of their relationships with the broader system that they live and interact with – be it education, service provision, governance, social norms, etc.
Even if we understand the complexity of water and sanitation issues, realities on the ground are often more nuanced. In most cases, the impulse is just to inform individuals or communities about the risk associated with contaminated water and how to prevent falling sick.
Yet, our experience and the evidence gathered through the RANAS studies show that several factors – from psychological, social, economic and governance – influence sustained behavioral change.
Changing a behavior depends first on a person’s motivation. It can happen quickly and fast if we achieve to ‘push the right button’. And it might not always be to the one way we think it is (or have been pushing for many years). Thus, if we want to achieve behavioral change, we first need to understand much better how people think and act, and then critically assess our work (and hygiene interventions). Put simply, first we need to change our behavior before others will change theirs.
What is up next? Besides spreading the word and applying the approach in multiple WASH projects across the globe, we’re currently simplifying and adapting it for Humanitarian Responses. We’re also starting to apply it to other sectors such as agriculture. We hope that you can read more on this soon – stay tuned!
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