Behaviour Change for Water, Sanitation and Hygiene

Having noted that providing access to services is not enough to change behaviour, the Sanitation and Hygiene Applied Research for Equity (SHARE) Consortium has been championing the importance of identifying novel and creative approaches to changing water, sanitation, and hygiene (WASH) behaviours across many countries since 2010. This policy brief documents SHARE's contribution to understanding behaviour change beyond simple education, and on the impact of these interventions. The structure follows a practical 5-step process for designing and evaluating interventions, as outlined in the behaviour-centred design (BCD) approach.

The steps include:

1. Assess: Researchers or programme designers begin by compiling evidence about the behaviour they want to change, the intended audience, the context for the intervention, and its parameters. For example, a systematised literature review that was conducted on the drivers of peri-urban sanitation improvement at the outset of the San-Dem in urban Zambia helped inform the design of the formative research.
2. Build: This stage uses formative research, which consists of field-based data collection, to help answer remaining questions and understand the contextually specific drivers of existing and/or target behaviours. Formative research prioritises methods that engage with the target behaviour as it exists in a particular setting, rather than methods that focus solely on what people say about their behaviour. The examples provided here - the aforementioned San-Dem, Banja la Ukhondo (Hygienic Family) in rural Malawi, Safe Start in peri-urban Kenya, and Mikono Safi in northeast Tanzania - highlight how these initial stages are essential for the development of a well-designed intervention. By exploring behavioural motives (e.g., through qualitative interviews with children to understand their perceptions of handwashing), researchers were able to identify key elements that would underpin an intervention.
3. Create: In designing a campaign and associated materials, the BCD approach recommends that the intervention be surprising and disruptive in order to maximise the effect on the target behaviour; otherwise, the old behaviours will simply persist. This stage is an iterative process that is often carried out by a creative team working closely with researchers or programmers. Examples cited here include the San-Dem project as well as the SuperAmma campaign. Supported by SHARE and the Wellcome Trust, the latter was a handwashing with soap intervention implemented in rural Andhra Pradesh, India. A local creative agency used formative research findings to design a campaign based on the key motive of nuture and status aspiration. A piloting process ensures that the design is underpinned by a theory of change and has emotive appeal to enable sustained behavioural change. Multiple iterations led to the development of the SuperAmma character, a mother who exhibits ideal handwashing behaviours so that her children will be successful in life. The focus on visual details meant that all characteristics were designed to create the feeling of aspiration suitable within the local context.
4. Deliver: Interventions can be delivered through many different channels, from face-to-face contact to mass media campaigns. For instance, the aforementioned SuperAmma intervention was delivered by street theatre artists, who were perceived to be better than rural sales promoters at engaging the crowd and building trust. Other activities included an inspirational animated film that provoked an emotive response in participants, as well as amusing live skits. Public pledging ceremonies were also used to encourage groups of women to promise to wash their hands at key times and ensure their children did, too. These pledges were publicly displayed on boards in each village. Other examples discussed here include: 'Safe Food, Healthy Child' in Nepal, the Weaning Food Hygiene intervention in the Gambia, and the Safe Start project in Kenya.
5. Evaluate: Interventions should include well-designed and conducted evaluations to understand the process of what worked and why, as well as assessing behavioural and/or health outcomes. To date, all SHARE-supported studies described in this brief have found positive effects on behaviour change at different levels, from the household to the community. While each campaign differed, they were all underpinned by a theoretical approach and an engaging behaviour change campaign. Some examples cited include:
   • In peri-urban Mali, researchers used the Hazard Analysis Critical Control Point (HACCP) approach to develop a small-scale hygiene intervention aimed at mothers. The intervention was effective in both changing behaviour and reducing the prevalence and intensity of faecal contamination – the latter by several orders of magnitude.
   • The SuperAmma evaluation measured whether the intervention had changed handwashing with soap behaviour at critical times. At baseline, this behaviour was rare in both the intervention (1%) and control (2%) groups. After 6 months, the proportion of handwashing with soap was 37% in the intervention group compared to 6% in the control group. A shortened version of the intervention was then implemented in the control group. After this, the proportion of handwashing with soap was 29% in both the intervention and control groups at 12 months follow-up.
   • In Nepal, 3 months after the 'Safe Food, Health Child' campaign was implemented, the proportion of mothers practising all 5 key food hygiene behaviours had increased to 43% in the intervention group, while they remained very low (2%) in the control arm.
   • The Gambia trial found that all behavioural outcome measures were significantly improved, with the exception of washing pots/utensils and placing on a clean surface. In addition, there was a significant reduction of a range of health and environmental outcomes, including diarrhoea.

The brief concludes with recommendations:

• Implementers should undertake formative research in order to ensure interventions respond to the local context.
• Funders should support researchers to use innovative designs underpinned by behavioural theories or frameworks to develop rigorous studies to understand the effectiveness of behaviour change interventions.
• Funders should ensure behaviour change interventions are well-resourced.
• Policymakers should embrace insights from behavioural science; considering all levels of decision-making is important to changing behaviour.