Socio-psychological determinants for safe

drinking water consumption behaviors:

a multi-country review

Prof. Dr. phil. et dipl. zool. Hans-Joachim MoslerMSc. Jonathan LiljeEnvironmental and Health Psychology Environmental Social Sciencesmosler@eawag.ch

Eawag: Swiss Federal Institute of Aquatic Science and Technology

Promotion of Behavior

Behavior

Person

How can we understand behavior?

Need to know these behavioral factors

Promotion of Water Disinfection

Drinking disinfected water

Factor AFactor B

Factor C

Factor D

Person

Behavioral Factors

How can we understand behavior?

Promotion of Water Disinfection

Drinking disinfected water

Factor AFactor B

Factor C

Factor D

Person

Behavioral Factors

Psychology is the Science of Behavior

For knowing the relevant behavioral factors we should use Health Psychology

Only studies which used behavioral psychological theory

The objectives of this review are

1.to show whether by using psycho-social determinants safe water consumption practices can be explained sufficiently well

2.to identify determinants which are with great probability useful to be targeted in all environmental and socio-cultural contexts 3.to recognize determinants which might be specific for different populations 4.to detect determinants which probably are specific for different safe water practices

We identified a total of 15 studies using health psychology in a quantitative way for explaining safe water consumption behavior

Theories encountered: Health Belief Model (HBM) (Rosenstock 1974)Protection Motivation Theory (PMT) (Floyd, Prentice-Dunn & Rogers 2000)Theory of Planned Behavior (TPB) (Fishbein & Ajzen 2010)Health Action Process Approach (HAPA) (Schwarzer 2008)RANAS Model (Risk, Attitudes, Norms, Abilities, Self-Regulation) (Mosler, 2012)

Types of safe water consumption behaviors9 studies household water treatment: 5 solar water disinfection, 2 boiling, 1 household level filter usage, and 1 chlorination. 5 studies on switching to safe sources 1 study looked at domestic well testing to monitor water quality1 study on cleaning behavior of water storage containers

10 Countries: •Benin, Burundi, Chad, Ethiopia (2), Kenya, Zimbabwe •Bangladesh (3), •Bolivia (3), Nicaragua, USA

Template: The RANAS-Model: Risk, Attitudes, Norms, Ability and Self-regulation

Mosler, H.J., (2012). A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. International Journal of Environmental Health Research, 22 (5), 431-449.

.

HBM

TPB

PMT HAPA

Authors CountrySafe water option/Target behavior

Vulnerability

Severity

Health Knowledge

Costs & benefits

Feelings

Others’ Behavior

Others’ Approval

Personal Importance

How-to-do Knowledge

Confidence in Performance

Confidence in Continuation

Confidence in Recovering

Action Planning/Action Control

Barrier Planning

Remembering

Commitment R2

POU household water treatment

Altherr et al.27 Nicaragua SODIS intention and usagen.a. n.a. o + + + o o o o n.a. n.a. n.a. n.a. n.a. n.a.

log .863

Graf et al.29 Kenya SODIS usageo o + + n.a. + n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a. n.a.

log .245

Kraemer et al.34 Zimbabwe SODIS intention and usage

n.a. n.a. o + o n.a. o n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a.log .70

0

Tamas et al.39 Bolivia SODIS water consumptiono n.a. o + + o + n.a. + o n.a. n.a. n.a. n.a. n.a. n.a.

.807

Heri & Mosler30Bolivia SODIS usagen.a. n.a. n.a. + + + n.a. n.a. n.a. o n.a. n.a. n.a. n.a. n.a. n.a.

.690

Tamas et al.39 Bolivia consumption of boiled watero n.a. o o + + o n.a. o o n.a. n.a. n.a. n.a. n.a. n.a.

.522

Sonego & Mosler37 Burundi

boiling water for consumption

+ o n.a. + + + + n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.

n.a.

Huber et al.39 Ethiopiaconsumption of fluoride free water from household filter

o o o + + o o + n.a. + n.a. n.a. n.a. n.a. o o log .679

Lilje et al.35 Chadchlorination of domestic drinking water

o + o o o + o o o + n.a. n.a. n.a. n.a. n.a. n.a. log .365

    switching to safe source                                  

Huber & Mosler31 Ethiopia

consumption of fluoride free water from community filter

o o + + + + o o n.a. o n.a. n.a. o o + +.568

Inauen et al.32

Bangladesh

use of arsenic-safe drinking water options

+ o n.a. + + + + n.a. n.a. + n.a. n.a. n.a. o n.a. n.a..688

Mosler et al.10

Bangladesh

consumption of arsenic free deep tubewell water

o o o o + + + n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a..590

Inauen et al.33

Bangladesh

use of arsenic free shallow tubewell

+ o o + + + + n.a. n.a. o + + n.a. o n.a. +log .89

4

    hygienic handling of water                                  Stocker & Mosler36 Benin

cleaning of water storage container

o + n.a. + o + o + n.a. + + o o o + +.625

    water testing                                  Flanagan et al.28 USA

domestic well water testing for arsenic

o o + + o + o o + + n.a. n.a. o n.a. o o.415

                                       

Authors CountrySafe water option/Target behavior

Vulnerability

Severity

Health Knowledge

Costs & benefits

Feelings

Others’ Behavior

Others’ Approval

Personal Importance

How-to-do Knowledge

Confidence in Performance

Confidence in Continuation

Confidence in Recovering

Action Planning/Action Control

Barrier Planning

Remembering

Commitment R2

POU household water treatment

Altherr et al.27 Nicaragua SODIS intention and usagen.a. n.a. o + + + o o o o n.a. n.a. n.a. n.a. n.a. n.a.

log .863

Graf et al.29 Kenya SODIS usageo o + + n.a. + n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a. n.a.

log .245

Kraemer et al.34 Zimbabwe SODIS intention and usage

n.a. n.a. o + o n.a. o n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a.log .7

00

Tamas et al.39 Bolivia SODIS water consumptiono n.a. o + + o + n.a. + o n.a. n.a. n.a. n.a. n.a. n.a.

.807

Heri & Mosler30Bolivia SODIS usagen.a. n.a. n.a. + + + n.a. n.a. n.a. o n.a. n.a. n.a. n.a. n.a. n.a.

.690

Tamas et al.39 Bolivia consumption of boiled watero n.a. o o + + o n.a. o o n.a. n.a. n.a. n.a. n.a. n.a.

.522

Sonego & Mosler37 Burundi

boiling water for consumption

+ o n.a. + + + + n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.

n.a.

Huber et al.39 Ethiopiaconsumption of fluoride free water from household filter

o o o + + o o + n.a. + n.a. n.a. n.a. n.a. o o log .679

Lilje et al.35 Chadchlorination of domestic drinking water

o + o o o + o o o + n.a. n.a. n.a. n.a. n.a. n.a. log .365

    switching to safe source                                  

Huber & Mosler31 Ethiopia

consumption of fluoride free water from community filter

o o + + + + o o n.a. o n.a. n.a. o o + +.568

Inauen et al.32

Bangladesh

use of arsenic-safe drinking water options

+ o n.a. + + + + n.a. n.a. + n.a. n.a. n.a. o n.a. n.a..688

Mosler et al.10

Bangladesh

consumption of arsenic free deep tubewell water

o o o o + + + n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a..590

Inauen et al.33

Bangladesh

use of arsenic free shallow tubewell

+ o o + + + + n.a. n.a. o + + n.a. o n.a. +log .8

94

    hygienic handling of water                                  Stocker & Mosler36 Benin

cleaning of water storage container

o + n.a. + o + o + n.a. + + o o o + +.625

    water testing                                  Flanagan et al.28 USA

domestic well water testing for arsenic

o o + + o + o o + + n.a. n.a. o n.a. o o.415

                                       

Can psycho-social determinants explain safe water consumption practices?

High quality of prediction of different safe water consumption behaviors: average R2 value of .637

Authors CountrySafe water option/Target behavior

Vulnerability

Severity

Health Knowledge

Costs & benefits

Feelings

Others’ Behavior

Others’ Approval

Personal Importance

How-to-do Knowledge

Confidence in Performance

Confidence in Continuation

Confidence in Recovering

Action Planning/Action Control

Barrier Planning

Remembering

Commitment R2

POU household water treatment

Altherr et al.27 Nicaragua SODIS intention and usagen.a. n.a. o + + + o o o o n.a. n.a. n.a. n.a. n.a. n.a.

log .863

Graf et al.29 Kenya SODIS usageo o + + n.a. + n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a. n.a.

log .245

Kraemer et al.34 Zimbabwe SODIS intention and usage

n.a. n.a. o + o n.a. o n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a.log .70

0

Tamas et al.39 Bolivia SODIS water consumptiono n.a. o + + o + n.a. + o n.a. n.a. n.a. n.a. n.a. n.a.

.807

Heri & Mosler30Bolivia SODIS usagen.a. n.a. n.a. + + + n.a. n.a. n.a. o n.a. n.a. n.a. n.a. n.a. n.a.

.690

Tamas et al.39 Bolivia consumption of boiled watero n.a. o o + + o n.a. o o n.a. n.a. n.a. n.a. n.a. n.a.

.522

Sonego & Mosler37 Burundi

boiling water for consumption

+ o n.a. + + + + n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.

n.a.

Huber et al.39 Ethiopiaconsumption of fluoride free water from household filter

o o o + + o o + n.a. + n.a. n.a. n.a. n.a. o o log .679

Lilje et al.35 Chadchlorination of domestic drinking water

o + o o o + o o o + n.a. n.a. n.a. n.a. n.a. n.a. log .365

    switching to safe source                                  

Huber & Mosler31 Ethiopia

consumption of fluoride free water from community filter

o o + + + + o o n.a. o n.a. n.a. o o + +.568

Inauen et al.32

Bangladesh

use of arsenic-safe drinking water options

+ o n.a. + + + + n.a. n.a. + n.a. n.a. n.a. o n.a. n.a..688

Mosler et al.10

Bangladesh

consumption of arsenic free deep tubewell water

o o o o + + + n.a. n.a. + n.a. n.a. n.a. n.a. n.a. n.a..590

Inauen et al.33

Bangladesh

use of arsenic free shallow tubewell

+ o o + + + + n.a. n.a. o + + n.a. o n.a. +log .89

4

    hygienic handling of water                                  Stocker & Mosler36 Benin

cleaning of water storage container

o + n.a. + o + o + n.a. + + o o o + +.625

    water testing                                  Flanagan et al.28 USA

domestic well water testing for arsenic

o o + + o + o o + + n.a. n.a. o n.a. o o.415

                                       

Determinants which are with great probability useful to be targeted in all contexts

Determinants which may or may not be targeted in all environmental and socio-cultural contexts

% Studies N of studies w/w-o effect

Behavioral factor determining the difference between doers/non-doers

86% 12/14 Perceived others behavior

80% 12/15 Beliefs about costs and benefits

71% 10/14 Feelings about the behavior

54% 7/13 Confidence in performance

50% 3/6 How-to-do knowledge

38% 5/13 Perceived others’ (dis)approval

33% 2/6 Personal importance

27% 3/11 Health knowledge

25% 3/12 Perceived vulnerability

20% 2/10 Perceived severity

Determinants which are with great probability specific for different populations

Differences can be observed between countries and project settings even within one country E.g. SODIS usage was determined by a different combination of factors for each of the six different studies Different combinations of factors explain boiling behaviors in both Burundi and Bolivia. Switching to safe water sources was also explained by varying psychological factors between - Ethiopia and Bangladesh- even within Bangladesh

Behavioral factors are always specific for populations and countries

Determinants which are specific for different safe water practices

Do we find common patterns or systematic differences in the factors identified as relevant for specific target behaviors? No systematic differences in relevant factors from the different types of HWTS options (SODIS vs. boiling vs. filtration vs. chlorination).

No systematic differences between relevant factors for HWTS options compared to switching to safer sources or well testing.

Implications for Practice1. Using psycho-social factors nearly all practices over all studied countries can be explained very well (mean explained variance 64%).

2.Perceived others’ behavior, costs and benefits as well as feelings (e.g. taste) about safe water consumption should nearly always be taken into account in behavior change campaigns.

3. Confidence in performance (self-efficacy), how-to-do knowledge, perceived others’ approval varied more strongly for different target behaviors but also between specific settings and populations and are thus to be evaluated from case to case.

4.The individual’s health risk perceptions played a role in only very few cases.

5. Between countries and between different types of safe water behaviors no systematic differences can be observed.

These findings highlight the usefulness of a systematic approach using psycho-social behavioral determinants in order to design effective behavior change strategies.

For more information about Systematic Behavior Change:

Side event “Systematic behavior change using the RANAS Approach:

an introduction and experiences of implementing organizations”

Convened by Eawag and HELVETAS

Thursday morning 8:30 – 10:00Windflower