Hygiene Behaviour Change: Lessons from the Fund

Bronwyn Powell on 3/07/2017 11:21 EST

This hygiene behaviour change e-discussion is the final in our three-week e-discussion series ahead of the Fund Learning and Reflection Event (FLARE). This online learning platform aims to capture and share project achievements and lessons and CSO approaches across three topics.  

Hygiene Behaviour Change

Recognising that good hygiene is one of the most cost-effective public health interventions but also that the changing of behavioural habits is extremely challenging, the CS WASH Fund has prioritised hygiene work to maximise the health benefits of water and sanitation investments. In the lead-up to the FLARE event, we consider the lessons learnt by CSOs in understanding the determinants of hygiene behaviour and changing those behaviours.

Week 3 e-Discussion (3 – 9 July 2017)

While it is recognised that some drivers of behaviour may be universal, there is increasing emphasis on understanding the local determinants of hygiene behaviour change. This has led to evolution of various frameworks to understand and influence individual and collective hygiene behaviours.

One such framework for understanding the local determinants of hygiene behaviour is the FOAM framework which defines the determinants of hygiene behaviour under these headings:

  • Focus: Who is the target audience and what is the desired behaviour?
  • Opportunity: Does the individual have the chance to perform the behaviour?
  • Ability: Is the individual capable of performing the behaviour?
  • Motivation: Does the individual want to perform the behaviour

 

 

 

 

 

 

 

 

 

Other hygiene behaviour change frameworks that seek to understand and change hygiene behaviours, and take a behavioural determinants focus rather than health-messaging focus, include the Evo-Eco model, the RANAS model and the Switch Framework.

This e-Discussion offers an opportunity for CSOs to learn from the experience of other CSOs engaged in hygiene behaviour change. To share these with each other, can you please respond to these questions:  

  • What hygiene behaviour change approaches do you, or your change agents, implement (for example, do they rely on health messages or behavioural determinants such as disgust, nurture, social affiliation, etc)? What frameworks inform this work? What’s the evidence that your approach is working, or not?
  • What have you found to be the greatest barriers to changing sanitation and hygiene behaviour?
  • What have you found to be the most effective approaches for triggering and sustaining sanitation and hygiene behaviour change? What approaches have you found to be ineffective in your context and why?

This e-discussion is facilitated by Mark Ellery and Bronwyn Powell.

  Mark is an independent water, sanitation and local governance consultant with more than 20 years of experience in the water sector.                                                

 Bronwyn Powell's picture   Bronwyn is the Knowledge and Learning Manager of the CS WASH Fund. 

Discussion

Molly_Goodwin-Kucinsky's picture
Human-Centered Design (HCD) is the starting point for all of iDE’s programs. In conducting HCD Deep Dive research, programs learn first-hand from households how they think about water, sanitation, and hygiene issues. This helps teams understand sanitation and hygiene barriers (lack of knowledge, inaccessible/unaffordable/undesirable products, etc.) as well as potential accelerators for behavior change (pride, desire to maintain family health, social pressure, etc.) With this knowledge, we design products and interventions that are affordable for poor, rural households and respond to the desires of local consumers.

Across all of our programs, iDE has seen health messaging to be important, but not sufficient in effecting behavior change. It has proven more effective to market sanitation and hygiene products by explaining how they will solve a household’s problems, rather than health benefits alone. This means iDE sales agents focus on understanding how poor sanitation and hygiene negatively impact a family, and then suggesting ways having a latrine or a handwashing device will improve the situation. If a family is motivated by a desire to fit in with others, a sales agent might mention how many of the neighbors have recently installed an improved latrine. Or, if a family is worried about the cost of a latrine, the sales agent may point out that having a sturdier, improved latrine costs more initially, but will ultimately save the family money if they don’t have to replace a homemade latrine that collapses with each rainy season. Each iDE program develops these marketing messages based on the context-specific barriers and accelerators identified through HCD research and revises them as market conditions change. We believe that if households purchase a latrine, they are more likely to be ‘bought-in’ and use it, so latrine sales are the ultimate measure of effectiveness of this approach. In addition, we survey customers regularly to understand their usage and satisfaction with their new latrine.

When it comes to hygiene, iDE has been successful by focusing on behavior change triggers. Rather than trying to change all handwashing behaviors at once, it is easier to focus on one or two behaviors in the context of the user’s day-to-day activities. For example, the purchase of a new latrine is an excellent time to promote handwashing after latrine use, since customers are developing new habit around latrine use. However, having a new latrine would not necessarily be a trigger for handwashing before food preparation. Our programs build on this by encouraging latrine customers to also install a place for handwashing near the latrine, and focusing messages on handwashing after latrine use. iDE Cambodia recently launched sales of two new latrine shelters with built-in handwashing devices as a way to build handwashing habits. iDE Vietnam works with the Vietnam Women’s Union to conduct village hygiene trainings, install handwashing reminder stickers on latrines, and launch a contest on hand hygiene knowledge. iDE Nepal and Bangladesh have both conducted hygiene training and handwashing demonstrations as part of school WASH programming. Many of these interventions are ongoing and we continue to track progress through knowledge and behavior surveys, presence of water and soap near latrines, and purchase of shelters with handwashing devices.
Md_Keramot_Ali's picture
Children Hygiene and Sanitation Training (CHAST) is a demand responsive, gender sensitive and child friendly approach. CHAST is for promoting personal hygiene among children. It is based on the well established Participatory Hygiene And Sanitation Transformation (PHAST) approach and uses a range of exercises and educational activities to teach children aged between six and sixteen about the links between personal hygiene and health. The approach is based upon the premise that hygiene practices are largely acquired during childhood and therefore it is much easier to change children’s habits than those of adults.

CDI2 WASH Program in Bangladesh has applied CHAST activities among 13000 students in 29 schools and successfully achieved an environment for attainment of child rights, reduced diseases and worm infestation among school children, environmental cleanliness in and around the schools, increased enrolment and retention, particularly of girl students and promote quality and joyful learning.

The CHAST activities is proven that personal hygiene practices are usually acquired during childhood and that it is therefore better to attempt changing the habits of children than those of adults.
Biplob Kanti Mondal's picture
Greetings from Bangladesh.

My Colleague Mr. Keramot Ali rightly mentioned that CHAST approach in schools is triggering to change the behavior of children. After completion of five steps of CHAST, we conducted survey to identify the outcomes of this approach. We found that the behavior of children has changed significantly specifically hand-washing with soap at five critical times, using slipper during latrine, food hygiene, bashing teeth at different times etc. Children also knew many things about safe water collection, storage and use, cleanliness of toilet, and most importantly good menstrual hygiene management etc. Another important findings is that each children is disseminating hygiene promotion information to around 21 people including parents, peers and relatives. They also now recognize what are the bad habits around WASH.

Besides, PHAST approach is also working well at the project communities, where predominately female participation is high.

So, both CHAST and PHAST approaches work in different circumstances for different age groups. It is also evident from diseases surveillance study that the rate of water and fecal borne diseases reduced significantly compared to the baseline data, which proves the approaches are working and making changes.
Mark_Ellery's picture
Thanks to Molly for detailing the human centred design & marketing approach supported by iDE’s programs. Thanks also to Keramot for describing the child hygiene and sanitation and training approach (CHAST) supported by the Australian Red Cross in Bangladesh and Biplob for highlighting the effectiveness of this approach.

While influencing hygiene behaviour is extremely difficult we know that the measuring of hygiene behaviour is probably even more difficult (i.e. hygiene behaviour knowledge is at odds with self-reported hygiene behaviour which is at odds with the observed hygiene behaviour). Do any CSOs have any experiences in measuring hygiene behaviour change that they would like to share?
Rashadul_Hasan's picture
Habitat for Humanity Bangladesh is working in the selected areas of northern Bangladesh for the promotion of improved sanitation and hygiene facility.

The main approaches of Habitat Bangladesh for the promotion of improved WaSH facilities are the awareness (using different tools) for community people on sanitation and hygiene, and the loan program for latrine construction. The awareness focused on hand washing after defecation and before eating, ensuring wastes management, stopping open defecation, promoting sanitary latrine and menstrual hygiene management. The Community WaSH Committees (CWC) were organized in the villages and trained to pursue the awareness program. The committee involved the local community leaders and enthusiastic young people for the awareness. Even the Imams (Islamic Clerics) were also involved in the awareness program, who share the awareness message on WaSH in the mosques and that had a good influence over the people in the villages.

The lower economic condition of the significant part of the community people is a barrier against changing sanitation and hygiene behaviour; many people wanted to have a tube-wells and toilets at their homes but cannot afford with their regular income. The loan latrine helped in this regards. Another barrier is, the support from the government relevant agencies of the government agencies for the program was not that high.

Organizing the Community WaSH Committee (CWC) and loan program for latrine are the most effective considering the effectiveness and sustainability of the program. Habitat Bangladesh has developed the capacity of the change agents as Community WaSH Committees (CWC) for pursuing the awareness activities and Community Based Organizations (CBO) to carry on the loan latrine program.
Gabrielle_Halcrow's picture
Hello all, in reply to the e-discussion questions. Within SNVs rural Sustainable Sanitation and Hygiene for All Programme in Asia - including in Bhutan and Nepal as part of the CS WASH Fund, we have been working on strengthening capacity on evidence based behaviour change communications as part of an integrated approach which also includes supply chain, sanitation demand creation and governance activities district wide. A key part has been on undertaking formative research with our govt partners since 2010, primarily using FOAM and SANI FOAM as the frameworks to analyse the different behavioural determinants for hand washing and sanitation respectively. The research being designed to meet the behavioural objective of interest. Recently we have also tried to engage with LSHTMs Evo-Eco model which was shared during yesterday’s webinair. The formative research findings are then used to inform communication and outreach objectives, messaging and are anchored within govt district level BCC strategies and so on. The process to do this was documented in guidelines for the teams and is online if anyone is interested to read further, Mark has shared it in the above link to behavioural change frameworks. We reviewed this process in 2016 as part of a learning event and reached a number of conclusions. Including that it was not so much which framework you used, but rather as long as there was one used to help make sense of the research findings which can be overwhelming unless the research is well defined, another is to ensure that the findings are actually translated into changed hygiene promotion practice and move beyond IEC material production and knowledge messaging. This has needed a very intentional focus on encouraging the health workers to look beyond what they may be more comfortable which, such as handwashing steps and health messaging. Facilitating a review process on practitioners experiences with IEC at the very start has been one way of reflecting on how effective people feel the current approaches have been and create some interest in improving on processes. I guess in summary then, the effectiveness of behaviour change communication is not only about the quality of the design process and the use of the frameworks, but also how it is understood and applied in practiced. Within SNVs programmes we see it being influenced by a number of things, including the capacity of govt line agencies and implementers, the skills and preferences of the communicators / facilitators and the priority given to hygiene promotion in general. Best wishes, Gabrielle, SNV
Tanoy_Dewan's picture
Hello Everyone,
Greetings from Bangladesh!

My two colleagues Biplob and keramot from CDI2 WASH- Bangladesh already mentioned CHAST and PHAST approach which we are applying in CDI 2 WASH. Apart from those we are also conducting different types of campaign in school and community such as school campaign on sanitation marketing, parents forum meeting, mass people gathering etc. CDI 2 WASH program also observing different types of national and international day observation like Hand washing Day, MHM Day, World water day etc. and conduct demonstration thorough which community peoples become aware about the mentioned subject.
Moreover; CDI 2 WASH program has started a new initiative to deliver hygiene promotion messages through mobile phone which will reach around 60,000 peoples at a time.
Bronwyn Powell's picture
Thank you to our contributors on the e-discussion. Yesterday we hosted a webinar with presentations on formative Infant Faeces Management with WaterAid PNG and on BCC for safe handwashing practices with SNV Bhutan. The video recording of this webinar is now available online here: http://www.cswashfund.org/learning-events/webinars/hygiene-behaviour-change-webinar-lessons-fund. If you missed it please do take the time to watch.

Gabrielle raises the importance of considering how health workers are used to working with IEC materials and health messaging and what will be required to encourage use of new approaches. There are interesting examples of household reminders, glow germ demonstrations, theatre and other creative ways of sharing messages shown in yesterday’s webinar from Bhutan. Likewise, WaterAid PNG is emphasising small doable actions their piloting of IFM. Our webinar presentations show work in behaviour change which aims to move beyond knowledge as a motivator and work towards behavioural determinants, or as Balaji described in his presentation – emotional rather than rational motives.
Anonymous's picture
Our project staff and our change agents do peer approach using with the PHAST tools for the hygiene behavior change. We conducted HP (TOT) to field staff, THC (Township Health Committee members (mostly are teachers and health staff who based in project villages) and then Trained teacher, health staff, field staff train to Peer Child, Peer Mothers and VHC (Village Health Committee) members. Trained teacher, health staff, field staff and VHC members facilitate the Peer to Peer training sessions that mostly are concentrated on demonstrations.

We have found that:
• Triggering without good facilitation skill
• Actively participation of the change agents for long-terms as a volunteer and
• Weakness of the follow up activities post triggering are the greatest barriers to changing sanitation and hygiene behavior.

The most effective approaches for triggering and sustaining and hygiene behavior change are:
• Peer approach using the CLTS and PHAST tools that supported by trained VHC, trained local health & education staff for both rural and urban area
• CLTS with follow up activities for the remote rural area
• CHAST & PHAST for the rural communities near urban and sub – urban area
Mark_Ellery's picture
The national benchmark of handwashing behaviour in Australian Hospitals at 5 critical times has been set at 80% by the Australian Health Ministers' Advisory Council from 2017 onwards.

http://ww2.health.wa.gov.au/Our-performance/Hand-hygiene/Monitoring-and-reporting-of-hand-hygiene/Hand-hygiene-public-hospitals

The high priority accorded to handwashing, the monitoring, the social pressure and auditing seem to have achieved very high levels of compliance in this particular setting. Do any CSOs have any data showing this kind of compliance in handwashing behaviour at critical times?
Mark_Ellery's picture
We shall be seeking to summarize the contributions at the FLARE and the main threads of this e-Discussion into a CS WASH Fund synthesis paper on Hygiene Behaviour Change.

If you haven't had the opportunity, and you would like your experience reflected in this synthesis paper, please feel free to continue to contribute to this e-Discussion.
Discussion *REQUIRED

Please note that you are now in the PUBLIC e-discussion section