Doing badly Behaviour change in Hygiene and Sanitation

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Doing badly? Behaviour change in Hygiene and
Sanitation

• Val Curtis
• Hygiene Centre, LSHTM
• Mimi Jenkins
• Hygiene Centre and UC Davies

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The Hygiene Centre

• Mission to develop and apply knowledge to help
  improve hygiene, sanitation and water use
  worldwide.

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Doing better?

• Why focus on behaviour?
• We can do better- professional, consumer focus
• Hygiene- PPP
• Sanitation- Consumer research, adoption behaviour
• Doing better requires a reflexive culture of
  praxis

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10,000,000 bacteria
1,000,000,000,000 viruses
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
(Curtis et al, TMIH, 2000)
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Leading Infectious Causes of DeathGlobal
Estimates 2002
3.9
4.0
3.5
3.0
2.8
2.5
Deaths in millions
1.8
2.0
1.6
1.5
1.3
1.0
0.6
0.5
0.0
Lower Respiratory Infections
HIV/AIDS
Diarrhoeal Diseases
Tuberculosis
Malaria
Measles
Source WHO 2004
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1.5-3M deaths
1 Bn episodes per year

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Interventions vs Diarrhoea
risk reduction
water quality
water quantity
sanit-ation
hygiene prom
hand wash
(Esrey et al, 1991)
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Diarrhoeal disease reduction from drinking water
and sanitation improvements
Reduction ()
Source Fewtrell L et al. Water, sanitation, and
hygiene interventions to reduce diarrhoea in less
developed countries a systematic review and
meta-analysis.Lancet Infectious Diseases, 2005
Intervention
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Impact of handwashing with soap on diarrhoea,
Curtis and Cairncross, 2003
47 reduction
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Impact of handwashing with soap on respiratory
infection - Rabie and Curtis 2005, updated with
Luby and Sandora, 2005.
23 reduction
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0 10 100
1000 10000 100000
(Disease Control Priorities for DCs, World
Bank/OUP, 2006)
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Vectors of infection
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Handwashing with soap after toilet/cleaning child

• Burkina 1 and 13
• Ghana 4 and 2
• Nigeria and 10
• Brazil and 16
• Peru 6 and 30
• Kyrgyzstan 18 and 0
• N. England 80 and 47

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WASH YOUR HANDS!
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WASH YOUR HANDS!
OR ELSE..!
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Behaviour change

• New approach
• Understand behaviour
• Attractive, modern
• Skills of industry

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Partners WSP, World Bank, USAID, Unicef, WHO
LSHTM, AED, CDC Unilever, PG, C-P, small-scale
producers and MF associations Govs of Ghana,
Peru, Senegal, Nepal, Indonesia, Tanzania,
Uganda, Kenya, South Africa, Ecuador, Madagascar,
Colombia, Vietnam.
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P
P

• Government
• Health, Social and
• Educational infrastructure
• Resources and expertise

P

• Scientific community
• Vision
• Credibility
• Knowledge

• Private sector
• Crafting communication
• Program design and control
• Optimising resources across channels and media

• ESAs
• Financial resources
• Expertise

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The Ghana Public-Private Partnership for
Handwashing
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Ghana Truly Clean

• OBJECTIVE Triple the rate of handwashing with
  soap by mothers and children after contact with
  faeces and before contact with food
• Reach 80 of target audience over 2 years via
• mass media
• direct community contact
• school, health and community infrastructure

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Consumer research
Communication plan
Target practices
What are risk practices?
Target audience
Whos problem?
Message content
What is motivation?
Channel mix
How do they communicate?
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Observed HW Rates

• 2 of Mothers washed hands with soap after
  cleaning childs behind
• 4 of Mothers washed hands with soap after
  defaecation

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• Motivations
• Disgust
• Nurture
• Social Acceptance
• Habit
• Never learnt
• Barrier
• Water is enough
• Lack of sensory cues of contamination

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Mothers TV Ad 1
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Activities

• National Launch
• Mass media
• 2 x TV ads, 2 languages, 3 TV stations, 5x a day
  for 6m
• 2 x radio ads, 10 languages, 18 radio stations,
  5x day for 6m
• 132 billboards
• Launches 110 districts
• Materials for District activities
• 132 road shows
• 11,500 mothers,
• 103,000 kids,
• 2930 teachers,
• 926 food vendors

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Impact

• 71 know TV ad
• 69 can sing song
• Reported HWWS
• -after defecation
• 13
• -before eating
• 41

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Human brain
Primate brain
Mammal brain
Reptile brain
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Motivation Mapping
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Understanding kids motivation
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Hygiene research questions

• Theory
• Advances in neuroscience, social psych, EP
• Perceptions, motivations, what is hygiene?
• Test predictions of new theory drivers of
  handwash behaviour?
• Evidence
• Impact of HW on ARIs, on other conditions?
• Potty programmes?
• Food hygiene?
• Practice
• What behaviour change from perfect progs?
• What time frame? What density of intervention?
  Sustainability?
• Best channel mix? Word-of-Mouth networks? New
  media?
• Impact of perfect schools programmes? Effect on
  homes?
• HW indicators? HFC indicators?
• Cost-effectiveness?
• M4P
• Maintaining a learning culture vs spending
  pressure

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Sanitation

• Understanding adoption behaviour, decision-making
  to accelerate coverage
• Latrine diffusion - Benin
• Toilet adoption behaviour - Ghana

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Latrine adoption patterns
521 villages Zou Department Benin 1993
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Adoption with urban distance - Benin
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Why do people want sanitation?
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Adoption Decision Stages
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Adoption rates Ghana
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Adoption barriers - Ghana

• Preference Stage
• never considered it, low awareness of benefits
• satisfied with existing practices
• Intention Stage
• low priority, competing priorities
• savings/credit difficulties, limited space,
  tenancy issues
• Choice Stage
• high (perceived) cost, no one to build, water
  table/soil problems, technical complexity
• No trigger, weaker dissatisfaction

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Creating new demand - Ghana
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Sanitation research questions

• Too many to list! But here are a few very big
  ones.
• The MDG gap and new approaches to accelerate
  coverage
• What is the true MGD target gap, and how much of
  it can be met by commercial marketing approaches?
  Where is the unfilled gap (rural/urban,
  segments)? What role do regulation and policy
  need to play?
• How to stimulate household demand
• What kinds of communications methods and
  channels, types of product features, services,
  and financing options are most (cost-) effective
  in getting more households w/out sanitation to
  invest in home sanitation in rural settings? In
  urban settings?
• For poor households, when does improving
  sanitation become a priority for investment of
  limited resources and what makes this happen?
• How do poor urban consumers make decisions about
  services and how can urban sanitation services be
  more effectively designed and marketed to
  increase uptake? (We know a lot more about
  product decisions)
• Business models and public and private roles for
  sustainable products and services
• What are viable business models for delivering
  excreta management products and services to
  accelerate uptake in dense unplanned urban and
  dispersed rural areas and what circumstances are
  critical for achieving sustainable delivery? What
  is the public sector role in supporting these
  efforts?
• How can DIY become a product and how do you
  market it?
• What constraints/facilitators do local sanitation
  industries face in expanding their markets?
• What have been effective and in-effective roles
  of public subsidy for sanitation and how can
  subsidy be used effectively to increase household
  uptake of improved sanitation among the poor?
• What are proven and potential municipal
  contracting models for public services in dense
  unplanned urban areas with poor households? Which
  minimize illegal dumping, maximize user fees,
  maintain service quality?
• Health
• What are usage patterns associated with different
  sanitation technologies and what implications do
  these patterns have for health impacts?

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extremely affordable, desirable products
technical RD
demand creation
product repertory
consumer accept.
market assessment
supply chain development
business model
market-oriented RD
market roll-out
M4P product pipeline
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Sanitation and Hygiene Research lags

• HIV/AIDS supports a thriving research
  community-1000s of researchers, papers -
  continual advance
• In SanHy they can be counted on two hands
• Immense numbers of problems still to crack- esp
  in behaviour
• We need a culture of reflexive praxis
• And huge increase in support to Southern Research
  Institutions

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Only then will we be doing well!

• END

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Thanks to collaborators

• Hygiene Centre
• Adam Biran,, Tom Clasen, Mimi Jenkins, Tamer
  Rabie, Wolf Schmidt, Beth Scott, Myriam Sidibe,
  Steven Sugden
• Environmental Health Group
• Sandy Cairncross
• WSP/Bank/USAID
• Param Iyer, Jennifer Sara, Kate Tulenko, Lene
  Jensen, Merri Weinger, Jason Cardosi
• Unilever
• Walter Gibson, Stewart Granger