Updated: Apr 6
Apprentice Sydney Grad's Behavior Change Journey
Note: The infographic above can be better viewed in detail by downloading the PDF file:
The water, sanitation, and hygiene (WASH) sector is concerned with providing universal, affordable, and sustainable access to all. It is a key public health issue within international development and one of the goals in the UN's Sustainable Development Goals. Improving access to WASH services can improve health, life expectancy, educational attainment, gender equality, and other important issues. It also greatly reduces illness and death while having a large impact on poverty reduction and socio-economic development.
Projects around the world have had varying degrees of success and improvement. This area can impact health and wellness and is something that many people overlook in development. The WASH sector needs to embrace behavioral science methods to make a greater, lasting, effective change instead of replicating hardware-focused projects from elsewhere. This is more important than ever as the world faces a global pandemic. This pandemic demonstrates that, while the biggest public health advice to stay safe is to wash your hands, millions of people cannot access vital resources like a toilet and handwashing facilities.
What is human behavior, what causes it, and, most importantly, how do we change it? Many programs experience 'slippage' when communities no longer use the services that programs provided once the implementers leave. Slippage is complicated because it hinges on behavior change; knowledge and awareness alone do not change behavior. This fundamental fact underpins the concept that programs are not enough; as soon as programs end, changed behaviors reverse. WASH programs should end and leave lasting change for communities. It helps no one to spend all this time, effort, and money and yet change nothing.
The WASH sector is beginning to apply psychology, sociology, and anthropology practices to achieve more sustainable behavior change and improve health. As an apprentice with FLUSH, I distilled an enormous amount of literature on behavior change, specifically in water and sanitation, to highlight a few strategies to consider when building behavior-centered programs. One of the key lessons from these disciplines is that our behaviors tend to be automatic and based on reinforcing experiences. We don't change behaviors unless we have a reason or motivation to change.
Positive Thinking: "I think I can"
The literature shows that long-lasting change happens when it's self-motivated and rooted in positive thinking. Messages around guilt can seriously backfire, and shame can stigmatize the very groups the campaign intends to support. For example, Community-Led Total Sanitation (CLTS) models are a common go-to design in sanitation programs that uses shame as a vehicle to change behavior. Evidence shows that it doesn't work in all situations and cultures. Also, research on emotions sees shame as problematic because it can be perceived as a direct attack on a person's self-conception or identity. Shame produces a range of negative psychological outcomes, including low self-esteem, anxiety, depression, anger, and even suicide.
In 2013, Cambodia's Ministry of Rural Development decided to remove shame from its CLTS program. The government amended this because shame in Cambodia is regarded as a culturally unacceptable form of social coercion. Instead of copying programs elsewhere, programs need to incorporate socio-cultural relevant information and traditions into programs. Designing culturally-appropriate behavior change mechanisms take time to understand cultural views and what motivates communities.
Social and Economic Factors: Keeping up with the Joneses
Economic and social factors better influence people's motivations than health knowledge. Analyses of what motivates people to adopt better hygiene practices show that social and economic aspirations are more influential than a desire for better health. This is not surprising: poor health often takes a long time to manifest, and social benefits like status and dignity are faster motivators.
Also, people find it harder to stay motivated for a long time when the results are intangible. It can be hard to plan for the future when people consider certain current conditions and their immediate focus on having shelter and covering daily living expenses. Program designs should take a holistic and broad-based approach to understand the people's daily lives and ensure that the program won't add undue burdens to them. Instead, programs should find ways to make people's daily lives easier and so that they can easily change their behaviors.
Nudges: Easy guidance to change
Nudge theory is mainly concerned with the design of choices, which influences the decisions we make, and focuses on indirect encouragement and enablement. It avoids direct instruction or enforcement; instead, it designs choices for people that encourage positive, helpful decisions, choosing, ideally, for society's wider interests and the environment. Nudges use routine rewards to instill lasting habit changes. Nudge interventions include environmental restructuring, modeling, and incentivization - all effective in influencing behavior. Nudges, of course, need to be positioned correctly in cultural contexts to create the desired behavior change.
Another study in Bangladesh painted playful footprints from the toilet to handwashing stations to nudge students to wash their hands after using the toilet. The study demonstrates how something very simple can be very effective. The program was effective because it was specific and consistent; every time someone went to the toilet, they saw it. It is also a great example of a cost-effective program with a singular goal of having people wash their hands. The program created a specific, language-free, easily accessible, and consistent nudge to all who used those facilities.
Edutainment: Looking up to role models
Social messages through entertainment offer positive and relatable role models to emulate. Edutainment (education + entertainment) celebrates positive and relatable role models, making it a powerful medium for changing behavior. For example, radio shows like Tanzania's Twende na Wakati (on issues surrounding HIV), Kenya's Shuga (on female empowerment and family planning), and South Africa's Scandal! (on sensible financial behavior) have made impressive gains in raising awareness, changing behaviors, and encouraging social dialogue.
The Bollywood movie (with the Swachh Bharat Mission) Toilet Ek Pram Katha used a women's toilet movement in India as a role model for adopting toilets. Programs should understand how people receive entertainment so they can utilize platforms that participants already use and enjoy.
Assessing Change: Are you doing it right?
As stated in Val Curtis' Inaugural Lecture, sanitation and hygiene need to look at the bigger picture of behavior and its process to create effective, long-lasting change. It is not enough to apply the factors highlighted, but rather look at how it's delivered and evaluate the results. What makes behavior change efforts successful, and how can we adapt and change what didn't work? Programs need to be receptive and take the time to create effective and sustainable interventions rather than fast fixes that rely on past success elsewhere.
We live within a globalizing world of interconnected communication and transportation of goods. People can normally travel and cross borders at a pace never seen before in history with advancements in almost every field and technology that is improving astronomically. This research has truly opened my eyes to the world of development, innovation, and future sector changes.
WASH has been slow to see the change and improvements that many other sectors have experienced. Much of it has to do with the fact that toilets are just something we do not like to talk about. But while they may not be glamorous or politically salient, they are truly fundamental to development and disease prevention.
It is easy to feel discouraged and hopeless when looking at global WASH data. Still, it is truly inspiring to see the space within which the field can and should grow. It demonstrates the need for new leaders to try new things and look at local culture and daily life to make new and effective programs. Emerging from a global pandemic, we must resolve to improve programming and rethink what will work more efficiently and effectively moving forwards - together.
AIDSCAP Behavior Change Communication Unit. (n.d). Behavior Change Through Mass Communication. http://etoolkits.dghs.gov.bd/sites/default/files/AIDSCAP%20-%20Behavior%20Change%20Through%20Mass%20Communication.pdf
Aunger, R., White, S., Greenland, K. & Curtis, V. (2017). Behaviour Centered Design A PRACTITIONER'S MANUAL. London School of Hygiene and Tropical Medicine. https://www.lshtm.ac.uk/sites/default/files/2017-03/BCD%20Manual.pdf
Bateman, M., & Engel, S. (2017). To shame or not to shame-that is the sanitation question. Development Policy Review, 36(2), 155-173. doi:10.1111/dpr.12317
Curtis, V. (2020). Inaugural Lecture. Lecture. https://www.lshtm.ac.uk/newsevents/events/discovering-behaviour
Dickinson, J. L., (2009). The people paradox: self-esteem striving, immortality ideologies, and human response to climate change. Ecology and Society 14(1): 34. [online] URL: http://www.ecologyandsociety.org/vol14/iss1/art34/
Dittmer, A., WaterAid. (2009). Towards total sanitation: Socio-cultural barriers and triggers to total sanitation in West Africa. Wateraid. https://www.communityledtotalsanitation.org/sites/communityledtotalsanitation.org/files/media/Towards_Total_Sanitation_-_barriers_and_triggers_in_West_Africa.pdf
Dreibelbis, R., Kroeger, A., Hossain, K., Venkatesh, M., & Ram, P. K. (2016). Behavior Change without Behavior Change Communication: Nudging Handwashing among Primary School Students in Bangladesh. International journal of environmental research and public health, 13(1), 129. https://doi.org/10.3390/ijerph13010129
Harvard Health Publishing. (2012). Why behavior change is hard - and why you should keep trying. https://www.health.harvard.edu/mind-and-mood/why-behavior-change-is-hard-and-why-you-should-keep-trying
IMDB. (2017, August 10). Toilet: A Love Story. https://www.imdb.com/title/tt5785170/
Jerneck, M., Voorden, C. & Rudholm, C. (2016). Sanitation and Hygiene Behaviour Change at Scale: Understanding Slippage. The Water Supply and Sanitation Collaborative Council (WSSCC). https://www.wsscc.org/media/news -stories/understanding-slippage
Mbuya, M. N., Tavengwa, N. V., Stoltzfus, R. J., Curtis, V., Pelto, G. H., Ntozini, R.,Kambarami, R. A., Fundira, D., Malaba, T. R., Maunze, D., Morgan, P., Mangwadu, G., Humphrey, J. H., & Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team (2015). Design of an Intervention to Minimize Ingestion of Fecal Microbes by Young Children in Rural Zimbabwe. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, 61 Suppl 7(Suppl 7), S703–S709. https://doi.org/10.1093/cid/civ845
Olson J. M. (1992). Psychological Barriers to Behavior Change: How to identify the barriers that inhibit change. Canadian family physician Medecin de famille canadien, 38, 309–319. PMID: 21221258; PMCID: PMC2145450.
Pichora-Fuller, M. K., (2015). Model Behavior Change. The Hearing Journal 68(5) - p 19-24 doi: 10.1097/01.HJ.0000465740.56146.cf
Rutter, T. (2016, March, 4). How the World Bank is 'nudging' attitudes to health and hygiene. The Guardian. https://www.theguardian.com/global-development-professionals-network/2016/mar/04/world-bank-nudging-attitudes-health-hygiene
Tombor, I., & Michie, S. (2017). Methods of Health Behavior Change. Oxford Research Encyclopedia of Psychology. doi:10.1093/acrefore/9780190236557.013.125
Wateraid. (2009). Towards total sanitation: Socio-cultural barriers and triggers to total sanitation in West Africa. https://www.communityledtotalsanitation.org/sites/communityledtotalsanitation.org/files/media/Towards_Total_Sanitation_-_barriers_and_triggers_in_West_Africa.pdf
WaterAid. (2017). Mass behaviour change campaigns. https://washmatters.wateraid.org/publications/mass-behaviour-change-campaigns-briefing-note