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ThematicDiscussion:
Sanitationandhygienebehaviourchangeprogrammingforscaleandsustainability
DiscussionSynthesis
ByTraceyKeatman,PartnershipsinPracticeLtd.
TableofcontentsTableofcontents.........................................................................................................................1
Introduction................................................................................................................................2
Programmingforscale.................................................................................................................2Defining‘forscale’insanitationandhygieneBHprogramming.............................................................3
WhatdoesBHprogrammescale-upmeanforWASHpractitioners?Expanding?Integrating?...............3Accesstoadequateandequitablesanitationandhygieneforall............................................................3
Ingredientsforsuccessfulscale-up........................................................................................................4Stakeholders’responsibilitiesandrelationships......................................................................................4
Sustainabilityforbehaviourchange.............................................................................................5Activeconsiderationofsocialandbehaviouralnorms...........................................................................5
Contextiskey...........................................................................................................................................6Behaviourchangetechniques:examplesandchallenges.......................................................................7
Hygienepromoters–whodoeswhat?.....................................................................................................7Systemisingbehaviourchange.................................................................................................................8Designingapproaches..............................................................................................................................8
Monitoringbehaviourchange...............................................................................................................8
ODFandslippage.........................................................................................................................9ODFandslippagedefinitions.................................................................................................................9Patternsofslippage..............................................................................................................................9Localstrategiesforpreventingormitigatingslippage..........................................................................11Slippagecriticalthreshold–impactsandmonitoring..........................................................................12
Concludingcomments...............................................................................................................12
Discussioncontributors.............................................................................................................13
Referencematerials..................................................................................................................14
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IntroductionTheWaterSupplyandSanitationCollaborativeCouncilCommunityofPracticeonSanitationandHygieneinDevelopingCountries(WSSCCCoP)andtheglobalSustainableSanitationAlliance(SuSanA)cametogetherinlateSeptember2015toholdajointthree-weekthematicdiscussiononsanitationandhygienebehaviourchangeprogrammingandsustainability.Itwasthefirsttimethetwonetworkshadcometogethertohostanonlinecollaborativelearningevent.Bothplatformshaveover5,000memberseachworkinginWASHandotherrelatedsectors.Hence,thisthematicdiscussionwasanopportunitytobringtogetherthesetwoglobalcommunitiestosharelearningandtoexplorelinksbetweenresearchandpracticeonbehaviourchange.
Thediscussionwasdividedintothreeinter-linkedsub-themestofurtherexplorehowbehaviourchangecanbebetterunderstoodandimprovedtoensurehealthandWASHoutcomesaresustained.Eachweekwasledbyspecialistsineachthemewhoframedthecontentfordebateandposedstructuredquestionsfordiscussionamongstonlineparticipants.Thethreesub-themesincluded:
1. Programmingforscale–weekonefocusedondefiningscaleforsanitationandhygienebehaviourchange(BC)programming,sharingexamplesofsuccessfulscale-up(ortheingredientsthereof)andunderstandingstakeholders’responsibilitiesandrelationships;
2. Sustainabilityforbehaviourchange–thesecondweeksoughttoexplorethesocialandbehaviouralnormsanddynamicsthatinfluencehygienepractices–specifically,handwashingandtheuseofsanitationfacilities;
3. Opendefecationfree(ODF)statusandslippage–thethirdandfinalweekofthediscussionfocusedonunderstandingterminology,exploringpatternsofslippageandlocalstrategiesforpreventingormitigatingslippage.
Thissummarypaperbringstogetherkeydiscussionpointsfromacrossthethreesub-themesandcaptureskeyreflectionsoneach.Theauthorofthissynthesisactedasthethematicdiscussioncoordinatoracrossthetwoonlineplatforms;shewouldliketoexpresshergratitudetoeveryonethatsharedtheirtimeandinsightsforthisexercise.
ProgrammingforscaleSuvojitChattopadhyay,aconsultantfocusedonmonitoringandevaluation,ledthefirstsub-themebyhighlightingthatthesanitationchallengeisacomplexand“wickedproblem”.ThekeychallengefortheWASHsectoristoinducelastingbehaviourchange:
“Theverynatureofcarefulsocialengineeringrequiredtobringaboutthisbehaviourchangeseemstoruncontrarytosomeofthefactorsthatmakeaninterventionscalable–anabilitytostandardiseinputsandbreakprogrammecomponentsdowntoeasilyreplicablebits.”
SuvojitcalledforWASHsectorpractitionersto:avoidtarget-drivenhardwareinterventionswhichwillneitherchangebehaviour,norcreatesocialcohesionbuttodoconstructionwell,withusableandlastingdesignsthatpromotelocalownership;learnfromeffectivemarketing(socialorotherwise)toreacheachandeveryperson;recognisethatconventionalapproachesarenotworkingandthatthereshouldbeafocusonpersonalandenvironmentalsanitationandhygieneasawhole(notjustensuringthatcommunitiesareODF)andalsoonstarting‘atscale’ratherthansettlingforincrementalcoverage.
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Defining‘forscale’insanitationandhygieneBHprogrammingAsanticipated,therewasagoodlevelofdebatetryingtounderstandwhat‘scalingup’meansindifferentcontextsforsanitationandhygienebehaviourchange;andthereforeprogrammingforscaledependsonhavingaclear,coherentandaccepteddefinition–whichisnotnecessarilyunderstoodoragreeduponbyall.AsElisabethvonMuenchsaid:
“Sowhatisitthatwearescalingup?Purelythosethingsthatdon'trequirehardwareintervention?Actually,everything,evenhandwashingandstopping[opendefecation]ODneedssomeformofhardwareintervention.Sothatcan'tbeit.Ithoughtit'sallabouthygienebehaviourchange(mainlyhandwashingandnotdoingODwhenyouhaveatoilet)-andnotreallyaboutgettingtoiletstothepeople,right?”
Parallelsweredrawntothechallengeofdefiningscale-upinthecontextofnutritionprogrammes,AlexisD’Agostinosaid:
“…theredidn'tseemtobealotofagreementwithinourfieldofwhatthattermreallymeant.Expandingprogrammingtonewgeographicareas?Integratingitintoalocalsystem?Both?Neither?Somethingelse?”
Participantsnotedthatthechallengesinsuchcomplementarysectorsmayprovideimportantlessonsthataretransferabletoscalingupbehaviourchangeprogrammes.
WhatdoesBHprogrammescale-upmeanforWASHpractitioners?Expanding?Integrating?Toscaleuporreplicateinterventionsonalargescale,sanitationhardwaresupplyandhygieneeducation(whichcanleadtobehaviourchange)requiretailoredeffortsastheyprobablywillnothappenatthesamepacenorbecomprehendedtogetherasahealthimprovement‘package’.Thisistheprimarychallengewhenconsideringprogrammingforscale–thedifferentelementsofWASHprogrammesdonotscaleupinthesamewayorthroughthesamemechanisms.Plus,scale-upinonedimensionmaynothaveacausalrelationshipwithanother.Forexample,RolandWerchotanotedthatbehaviourchangeatscalealonewouldnotnecessarilymeanthatscaleisalsoreachedonaccesstosanitation.
AsPeterBuryhighlightedthereisaneedtodistinguishbetweenbutalsopromoteintegrationofsanitationandhygiene(wherebyhygieneeducationcaninfluencebehavioursandhygienicpractices)andnottreatthemasseparateactivities.Similarly,participantsnotedthathygienecanneverbesustainedwithoutadequatewater–sothefocusremainsonwaterquantitytoo.
“Improvementinhealthdependsthereforemoreonsanitationonceaminimumofclean(utility)waterisavailable.”(QuotefromRolandWerchota)
Dependentonthecontext,therehastobesomewateraccessintegratedwithasanitationservice(on-site,shared,household)andbehaviourchangetohavetheimpactrequired.Viewsonhowinterventionsaresequenced,whichstakeholdersareinvolvedandwholeadstheprocess(community,government,privatesector,NGOs)differedamongparticipantswhohighlightedthedifferentneedsindifferentcontexts(e.g.rural,urban,peri-urban,inschoolsorhealthcentres,post-conflict,internallydisplacedpersoncamps,etc.).
AccesstoadequateandequitablesanitationandhygieneforallThissub-themewasdiscussedduringthesameweekthattheUNGeneralAssemblycametogetherinNewYorktoagreeandfinallyadoptthenewSustainableDevelopmentGoals.Ofrelevancetothisdiscussionisthecommitmenttotarget6.2whichdemandsanaccelerationofpaceandpracticeforsanitationandhygiene:
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By2030,achieveaccesstoadequateandequitablesanitationandhygieneforallandendopendefecation,payingspecialattentiontotheneedsofwomenandgirlsandthoseinvulnerablesituations.
Themandatetoachieveaccessforallhasclearimplicationsforprogramming–itreinforcestheneedforensuringequitableandinclusiveservicesaswellasproducts,hygieneeducationandongoingsupportorfollow-upoverthelongterm.Similarly,intermsofintendedpublichealthimpact,Suvojithighlighted:
“…withouttheinclusionofallhouseholdsinacommunity,gainsfromimprovedsanitationcannotberealised.Unlessallfamiliesadopthygienicsanitationpractices,wewillnotmakeadentontheincidenceofdiseaseprevalence.”
Doesthismeanscalinguphygienicsanitationpracticesalwaysmeansreaching100percentofthepopulation?ItwasagreedthatBHcannothappenovernightbutisagradualprocessthatrequiresongoingfocusandsupportduetopopulationgrowth,peopleforgetting,andtheneedforrepeatededucationinschoolsandthroughmedia.Accessforallsurelyimpliesongoingactiontoensurechangedhygienebehavioursandpracticesaresustained.
Ingredientsforsuccessfulscale-up
Inthecasesofsuccessfulscale-up,wereprogrammesinitiatedandsustainedbygovernmentalornon-governmentalactors?Whatarethekeyelementsofasuccessfulpartnership?Howcanwestrengthennationalownership?
Therewasanexampleprovidedofhowpartnershipsandconvergentactionarecentraltoscalingup–AnandShekharsharedhowtheMinistryofDrinkingWaterandSanitation,theGovernmentofIndiaandtheGlobalSanitationFundhaveannouncedtheShillongDeclarationon‘PromotingSustainablePartnerships’.Inaddition,theprocessofachievingODFstatusinNadiaDistrictinWestBengal(seesabarshouchagar.informore)requiredthatstakeholdersshare‘keyvalues’toensuresuccessatscale.Thesevaluesincludedecentralisation,jointplanning,co-financingandcollectiveaction.
Severalpeoplecommentedonhowthereisnotaone-size-fits-allapproachandthatthereisaneedtolookbeyondtheWASHsectormore,tointegrateeffortswiththoseofothersworkingonlivelihoodsandothersectors.
Stakeholders’responsibilitiesandrelationshipsParticipantshighlightedthatsanitationBHcampaignsneedtobelocallyledandsustainedbylocalgovernmentalorcollectivecommunityresourcesplusinter-ministry,aswellascommunity,buy-inandcoordination.Achievingthisiseasiersaidthandone.Forexample,Anandnotedthat:
“Generally,programmesofdevelopmentorganisationsareguidedbyvalueswhichmayormaynotmatchandconvergewithothers.Scalingupdemandsscalingupofcoresetofvaluesthatpromotesustainabilityofbenefits.”
Giventheenormityofthechallengetoreachscalethereisarecognitionthatoneorganisationorstakeholdergroupcannotdoeverythingneededtoreachwiderscalealone.Unlessallpartieshaveanagreed,definedunderstandingofwhatitistheyaretryingtoachievetogether,itisunlikelytheywillachievetheirgoals.Thehypeandrhetoricofpartnershipsooftenconcealsthedifficultrealitiesofworkingwithotherorganisations,especiallygovernments.
Suvojitpromptedadebateontheroleofpublichealthengineers–theirroleinthedesignandexecutionofservicesandalsoforbudgetholdingratherthanthatrelatedtobehaviourchangesoftware.LalitaPulavartiprovidedanexamplefromIndia:
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“…InOrissatheExecutiveEngineers(ofajointWATSANdepartment)arestillinchargeofthesanitationprogram.However,thisdoesnotmeanthattheyarepayingattentiontostructuralordesignissues!Itonlymeanstheyareinchargeofthemoneythatflowsinthroughthescheme.Sub-contracting(andtheresultantkickbacks),andnotgivingownershiptothecitizenstogetthetoiletbuiltthemselves(duetoscaleissues/laborissues[skilledmasons,etc.]oranyotherreason)iskillingthescheme.UnlessthischangesunderSBM,wewillseemoreofthesameinIndia.”
Thereisalsoaneedtoworkmorewithnon-traditionalpartners–suchas"anthropologists,sociologistsandpsychologists"insanitationprogrammingtobetterunderstandthedeterminantsofmassbehaviourpatterns.Plus,perhapstheycanassistmoreinraisingawarenessoftheneedforsanitationandhygieneamongstpeople,notablythepoorest,whohavesomanycompetingprioritiesfortheirtimeandmoney.Suvojitalsonotedtheprominentrolethattheprivatesectorcanplayinthepromotionofhygieneandsanitationcampaignsandexpansionofprogrammes:“Whetherintheformofinnovativecommunicationcampaigns,orfinancingthroughCSR,privatesectorresourcesneedtobeharnessedthroughmutuallyfruitfulcollaborations.”
Attheendoftheweek,Suvojitprovidedreaderswithhis‘sixstepformula’toasuccessfulsanitationandhygienecampaign:
1. Donotapproachcommunitieswithasinglemessage(buildandusetoilets),butwithacomprehensivehealthandhygieneintervention.
2. Insteadofbeingsubsidy-averse,bereadytoexperimentuntilyougetthedesignright.3. Playonlocalpowerrelations.4. Allowcommunitiestoevolvetheirownnormsaroundindividualandcollectiverightsand
responsibilities.5. Donothurryintoscalingup.6. Perhapsmostimportantly,beconscientiousaboutquality.
SustainabilityforbehaviourchangeThesecondweekexploredthesocialandbehaviouralnormsanddynamicsthatinfluencehygienepractices–specifically,handwashingandtheuseofsanitationfacilities.Bywayofdefinition:
"Socialnormsaresociallyacceptedoragreedvalues,beliefs,attitudesandbehaviours–reflectingwhatapersonconsidersrightandexpectedbehaviour.Thisisrelatedtohowpeoplethinkothersexpectthemtobehave,andwhatmostotherpeopledo."(IDS,2015)
AsthepreviousweekfocusedonunderstandingwhatmightberequiredtoprogrammeforscaleinBHactivities,thesecondweekofconversationsfocusedonhowBHcanbesustainedonceprogrammesareinplace.
ActiveconsiderationofsocialandbehaviouralnormsHenrietaMutsambi,theWASHManagerattheInstituteofWater&SanitationDevelopment(IWSD)promptedthediscussionbysharingherknowledgeandexperiencesofbehaviourchangeeffortsinZimbabwe.Shehighlightedthat:
“Healthbehavioursshouldbeengrainedinone’salreadyexistingeverydayculture.Scaringtacticsdonotworkandpeopleincludingchildrendonotbelievethattheywill‘diejustlikethat’iftheydonotuseatoiletorwashtheirhands.BUTwhyarewepushingforhandwashingtohappen–toavoiddiarrhealandotherrelatedcommunicablediseases.”
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Henrietawentontohighlightsomeofthekeywaysformainstreaminghandwashingandlatrineuseinexistingsocio-culturalbeliefsandnorms.Forexample:usingreligiousscripturetoreemphasisehandwashingwithdifferentfaithcommunities;buildingontraditionalbeliefsabouthygiene(e.g.theNdebelepeopleinZimbabwedonotbelieveineatinginpublicplaceswheretherearenofacilitiessuchashandwashing);experientiallearning(showvisuallyhowhandwashingwithorwithoutsoapcleanshandsdifferentlybyusingawhitetowelforhand-drying);andthevalueoflinkinghygienetosocialstatusandconceptsofdignityandpridewhichcanworkinsomecontexts(althoughnotall).Severalcontributorsnotedthevalueofinfluencingtheyoungsothathygienicpracticesbecomeroutinebehaviour.
ContextiskeyUnderstandingtheincentivesandinternalmotivationsforbehaviourchangeiskeytodesigningbehaviourchangetechniques–suchtechniquesmustbetailoredtothecontext.Forexample,SamFrenchdescribedWaterAid’sexperienceinWestAfricawhentheorganisationwastakingwhatithadlearnedaboutCLTSfromBangladeshandtailoringitfordifferentcontexts:
“Wehadtolearnalotaboutthesocio-culturalcontextandtailorappropriately–wesoonlearntthat'shame'didnotmotivatecommunitiesinNigeriatochangetheirbehaviour,butratherpositivemotivatorssuchasthefeelingofdignityandpride.”
NabilChemalysharedhisexperiencefromtheGIZWaterProgrammeinBurundi,wherebehaviourchangeinterventionsweredesignedtotargetmainlypsychologicalfactorsandweretestedandassessedintheshortterm(onemonthafterimplementingtheintervention)andmediumterm(6monthsafterimplementingtheintervention)todeterminescale-uppotential.Thesanitationbehaviourchangeinterventionsconsistedofacombinationofthefollowinginitiatives:
• Awarenesssessionstohouseholds+trainingforlocalconstructionworkers+in-kindsubsidiesupto50%ofthecostofalatrine;
• Awarenesssessionstohouseholds+trainingforlocalconstructionworkers+assistanceinhouseholdfamilyplanningtosaveenoughmoneyfortheconstructionofalatrine;
• Awarenesstohouseholdsthroughtheatreasameansofmasscommunication+trainingsforlocalconstructionworkers.
Nabilnotedthatmanyotheractivitieswereundertakentocreateanenablingenvironmentforthesuccessoftheseinterventionssuchastraininghealthpromoterstoconductawarenesssessions,trainingpharmaciststoproducechlorine,traininglatrineconstructionworkersandplumbers,buildingdemonstrationlatrinesinpilotareas,etc.Theshort-termevaluationofsanitationinterventionsshowedmanyvaluablelearningpoints,includingthat:theatreasameansofmasscommunicationdidnothaveamajorimpactonaccesstosanitationandthereforehasalimitedpotentialwithoutconsistentfollow-up;awarenessusinglocalagentsisaneffectivetechnique,butproperfollow-upandmonitoringfromlocal,provincialandcentralsanitaryauthoritiesisnecessary;and,thefirstawarenesssessionstohouseholdsweremoreeffectivethanfollow-upsessionsplannedaccordingtotheapproachproposed.
Asnotedinweek1,BHisalong-term,slowprocessthatdoesnothappenuniformly–additionally,severalcontributorsnotedthatthetimelimitsofmanylocalNGOinterventionsaretooshort.Similarly,FranckFlachenbergnotedthatsomeprogrammes“justjumpfrombehaviourchangeobjectivesstraighttotheactivities,withoutgivingmuchthoughttowhypeopledowhattheycurrentlydoandwhatmaybepreventingthemfromadoptingthehygienebehaviourspromoted.”Analysisby3ieshowedthat:
"Barrierstobehaviourchangedependonthestageoftheproject.Manystudiesassessthehealthbenefitsofinitialuptakeofsafewater,hygieneandsanitationtechnologiesand
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practices.Butfewstudiesconsidersustaineduse.Theearlyprojectperiodmaybecharacterisedbyenthusiasmoverthenewtechnologyorpromotionalactivities.Althoughexternalsupportendsduringtheearlypost-projectperiod,thepromotionalmessagesmaystillbefreshinpeople’sminds.However,influentialhouseholdmemberswhowerescepticalmayreasserttheirdominationduringthisphase.Andfinally,inthelatepost-projectperiodstockouts,technologyfailureorpoormaintenancesystemscanposeaseriousthreattosustainedadoption."
The3ie-supportedsystematicreviewalsofoundthat:
"...frequent,personalcontactwithahealthpromoteroveraperiodoftimeisassociatedwithlong-termbehaviourchange.Thereviewsuggeststhatpersonalfollow-upinconjunctionwithothermeasureslikemassmediaadvertisementsorgroupmeetingsmayfurtherincreasesustainedadoption."
IWSD,GIZ,ConcernWorldwide,WaterAidand3iecontributionsallhighlightedthevalueoftakingaholistic,multi-prongedapproachtoincreasethepotentialforBHtobesustained.Wherethereisinformation,educationandcommunication(IEC)providedtocommunitiesinvariousmediapluspracticalsupporttoensurethereisanenablingenvironment,thetechniquesusedappeartohavemorechanceofsuccessandmaybebettersustained.Hence,usingtoolsthatmoresystematicallyanalysebarriersanddriverstowardsBHshouldbeplannedintoprogrammesfromthestart,andsubsequentBHcampaignsshouldbebasedonthecontext.
Behaviourchangetechniques:examplesandchallenges
Hygienepromoters–whodoeswhat?FranckFlachenbergsharedConcernWorldwide’sapproachtohygienepromotion,highlightingthatmanyWASHprogrammesrelyontraininghygienepromoterswhoareusuallymembersofWASHcommitteesthathavebeensetuptomanageinfrastructure.Franckarguedthatforsustainabilitypurposesitwouldbebettertorelyonexistinglocalnetworks,suchascommunityhealthworkers,andthathygienepromotionshouldbeintegratedasmuchaspossiblewithintheexistinghealthsystemratherthansettingupparallelsystemssuchasWASHhygienepromoters.
JihaneRangamaagreed,providinganexamplefromBurkinaFaso,wherehygienepromotionactivitiesareperformedbylocalvolunteers(membersoflocalwomen'sassociationsforexample).However,feedbackshowedthatthevolunteers’motivationdecreasedquitequickly,andtheresultsintermsofbehaviourchangeinterventionswerenotasgoodasexpected.SamFrenchaddedthatcrosssectorintegrationisalsokeytoamulti-prongedapproachwherebyschools,healthcentres,midwives,etc.alluseandreinforcethesamemessages.
TomDavissuggestedhoweverthatthefocusonusingpaidprofessionalsforhealthpromotionisunfoundedandreferredtoresearch1thatfoundthatprojectsusingCareGroupshaddoubletheadoptionofhandwashingwithsoapasprojectsthatdidnotuseCareGroups.CareGroupsrelyonvolunteers.SusanDavisalsocontributedtothispointbyhighlightingastudythatcomparedCLTStotheCommunityHealthClubsapproach(WhaleyandWebster,2011).
"Whilstbothapproacheseffectivelyencouragedmeasuresthatcombatopendefecation,onlyhealthclubswitnessedasignificantincreaseintheadoptionofhandwashing.However,CLTSprovedmoreeffectiveinpromotinglatrineconstruction,suggestingthatthe
1Georgeetal,2015EvaluationoftheeffectivenessofcaregroupsinexpandingpopulationcoverageofKeychildsurvivalinterventionsandreducingunder-5mortality:acomparativeanalysisusingthelivessavedtool(LiST),JohnHopkinsBloombergSchoolofPublicHealth,USA.Availableat:http://www.biomedcentral.com/1471-2458/15/835
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emphasistheCHCsplaceonhygienepracticessuchashandwashingneedstobecoupledwithanevenstrongerfocusontheissueofsanitationbroughtbyCLTS."
SystemisingbehaviourchangeWaystosystematisebehaviourchangetechniquesandtounderstandsocialnormshavebeendeveloped.OnesuchsystemwassharedbyProfessorHans-JoachimMoslerfromEawag–the“RANAS”frameworkthatseekstoprovideaprocessforsystematicallymappingpotentialbehaviouraldeterminants(basedonhumanpsychology)andthenlinkingthempracticallytospecificbehaviourchangetechnologies.Withsuchframeworks,practitionersareabletodevelopatailored,context-specificapproach.TomDavisalsoreferredreaderstothedifferentdeterminantsfoundforthe18BarrierAnalysisstudiesonhandwashingwithsoapshownontheFoodSecurityandNutritionNetwork'sBehaviorBank.
DesigningapproachesProfessorMosleralsopointedoutthatdesigningcontext-specificapproachescouldbebetterdonebyengagingwithcreativeagencies–whowouldalsohavetounderstandthecontextandaudience–whichisanapproachthatmanyprivatesectororganisationsuseforbehaviourchange.ItwasnotedthattheWASHsectorcoulddomoretobetterunderstandandlearnfromtheprivatesectorabouttheirexperiencesandexpertiseonthebasicmechanismsorstructuresbehindthedesignoflarge-scalebehaviourchangemediacampaigns.ThisistoensurethesedesignprinciplesarecoherentlyaddressedinthedesignofWASHprogrammesandcomplementwhateverishappeningonthegroundonpersonalhealtheducationandfollow-up.
Havingacomplementaryapproach(massmediapluslocal,sufficientlylong-termsupportandfollow-up)canclearlyreaprewards(asnotedabove).Yet,howisthissystematicallyplannedforanddeliveredinaprojectorprogrammecycle?HygienebehaviourchangerarelyseemstobeelevatedtothissystematicplanningstatusinWASHprogrammes–despitetherecognitionofitsimportance.Italsorequiresustoworkinpartnershipwithothersthatwemaynotusuallyengagewith(ashighlightedearlier).
MonitoringbehaviourchangeIntermsofmonitoringandevaluatingBH,Franckalsohighlightedthat“arobustM&Esystemisassociatedtoeachnewcampaignsoastobeinpositiontoassessitsresultsintermsofeffectivebehaviourchange(andnotjustimprovementinknowledge).”
TakudzwaNoelMushambahighlightedthatthe“absenceofcasesorlowprevalenceofwaterandsanitationdiseasesisnotnecessarilyandindicatorof‘improvedbehaviour’”.Hedrewattentiontotheepidemiologictriangle,whichshowsthelinkagesbetweentheagentofdisease,thehostandtheenvironmentnotingthat:
“Wearemoreaproductoftheenvironmentthanwhatpeopletellus.Thesamemessagemeansdifferentthingstotwopeople.Tooneitmeansopenthetapandahandsanitizerandtoanotheritmeansbuyextrasoap,traveltoaborehole8kmawayandgetanextrabucketofwaterandwashbeforeyoueat.Infrastructureplaysahugerolenotonlyinreducingexposurebutalsoinfosteringnewbehaviour.”
Finally,HannaWoodburn2fromThePublic-PrivatePartnershipforHandwashing(PPPH)notedthatduringUNdiscussionsontheadoptionoftheSDGs“whenbehaviourchangewasmentionedasbeingkeytoachievingthesegoalsresponseswereoftenabstract”.
2HannaalsodrewparticipantsattentiontothePPPHHandwashingBehaviourChangeThinkTankeventheldatAfricaSan4inDakar,Senegal,whichlookedatthreebigideasinhygienebehaviourchange:emotionalmotivators,behaviouralsettings,andthescienceofhabit.
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Somonitoringeffortsalsoneedtobemulti-faceted,holisticandabletochangealongwithcontextualchangesandthestagesofparticularprogrammes.
ODFandslippageInthethirdandfinalweekofdiscussions,theconversationmovedontoaddresswhathappenswhenchangedbehaviours‘slipback’orwhereBHprogrammesmayrequireextrasupport.ColleaguesfromtheGlobalSanitationFund(GSF)thatledtheweekhighlightedthefollowing:
“Large-scalebehaviourchangeorientedsanitationprogrammesoftenfocusonsupportingcommunitiestoachieveopendefecationfree(ODF)status,criteriaforwhicharelocallydefinedbutoftenincludeacompletestopofpeopledefecatingintheopen,accesstobasicbutfly-prooflatrinesforallcommunitymembers,andpresenceofhandwashingstationswithwaterandsoaporashclosetothelatrines.AstheseprogrammesmatureandwhenthechallengeshiftsfrombringingcommunitiestoODFtosustainingtheirODFstatus,manyareconfrontedwiththeissueofslippage–areturntopreviousunhygienicbehavioursoraninabilityofsomeorallcommunitymemberstocontinuetomeetallODFcriteria.However,thereisalackofclarity(oratleastacceptable/universaldefinitions)ofwhatslippageactuallyisandthereisnopanaceaforhowtocometotermswithslippage,whichisdynamicandcontextspecific.Whatwedoknowisthatslippageisanexpectedaspectofsanitationinterventions,especiallythoseatscale,andNOTasignofafailurethereof.”
ODFandslippagedefinitionsTworelevantcommentsweremadeinconnectiontoGSF’sdefinitionofODFandslippage.KimberlyMcLeodagreedwiththethreemainprinciplesforrecognizinganODFvillageandreinforcedthatthe“presenceofhandwashingstationswithwaterandsoaporashclosetothelatrines”shouldgofurtherandstatethatvillagersmustalsobe“washinghandsproperlyatcriticaltimes.”AkhileshGautamalsoreflectedonwhattimeperiodcouldbeconsideredforhavingachievedODFstatusasa“stable–sustaineduse”ofatoiletbeforebeingconstruedas‘slippage’.AkhileshnotedthatinhisfieldexperienceinIndia:
“Inmanyvillagesthe"stable"periodofsustainedbehaviouroftoiletusewasneverachievedinthefirstplaceandthereforecallingitslippageiserroneousandhasdifferentimplicationsforstrategycoursecorrectioninthesanitationprogramming.”
Patternsofslippage
“Sanitationandhygienebehaviourchangeisanon-linearprocessthatmightlooklikethis:acommunityistriggered,endeavorstoreachODF,isdeclaredODF,slipsbackrepeatedly(duetovariousindividual/collectiveandinternal/externalfactors)tonon-ODFstatusfollowedbyinterventionstoregainODFstatus.Acommontrendseemstobethatthemoreofteninterventionsarerepeatedandfollow-upsupportisprovided,thelessdramatictheslippagewillbeuntileventuallyalevelofmaturityismetandbehaviours‘stick’.”(GSFcolleagues)
IntermsofODFslippageexperiencedindifferentprogrammesaroundtheworld,therewasaninterestingselectionofreasonsforandpatternsofslippage–someofwhichwereexternalinfluencingfactors(e.g.socio-cultural,environmental,financialandpoliticalaspects)andsomewhichsanitationandhygieneprofessionalsmayhavemorecontrolover(e.g.poorlydesignedprogrammesorprogrammaticlimitations).ThefollowingbulletpointssummarizethekeyODFslippagefactorssharedbycolleaguesonbothdiscussionplatforms:
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Ø Socio-culturalaspects–communalconflict;IDPs’needsandimpactonavailablelocalfacilities;vulnerablepeopleunabletomeetODFwhichimpactsonallcommunity;lackofpeerpressurefromcertifiedODFcommunitiestotheircolleagues;
Ø Environmentalaspects–seasonalorotherflooding(leadingtolossoflatrines,fewerpossibilitiesforfollowupbyfacilitators);toomuchrainsolessashforhandcleaningandcleaninglatrines;
Ø Financial/economicaspects–affordabilityofsuitablehardwarebytheurbanpoor;poormanagementoffundsforBHandrelatedfollowup;
Ø Politicalaspects–“Unhealthycompetitionbetweenlocalgovernmentstomeetcentralgovernmenttargets,atall(non-financial)cost”;
Ø Programmaticlimitations–o Poororweakcommunity-ledtotalsanitation(CLTS)triggeringfacilitation;o Unclearmessagingonhygieneandpoordeliveryofmessages,e.g.peopleopenly
defecateoutsidetheircommunityforconvenienceindicatingthatthemessageisnotfullyunderstood,thatthere’salackofawarenessandmotivation,orthatthemessagehasnotbeenpassedontotheentirefamily/householdandlowlevelsofactualandengrainedbehaviourchangeduetolowqualityimplementation;
o Hastyandlowqualitybuildingoffacilitiesthatdonotmeetnationalstandardsandwherethereisnopost-constructionmaintenance/repairsprovision;unequalorinconsistentsupplyofhardwarefacilitiestomeetdemandorunsuitable,inappropriatesanitationfacilityforthecontext;
o Lackofsufficientand/orwell-fundedfollow-up,e.g.supportstructures,maintenance/repairoptions,bygovernment,environmentalhealthstaffornaturalleaders,etc.;
o Lackofsufficientengagementofthemunicipality.
CarolienvanderVoordensharedlearningfromMadagascarthatindicatedthatsanitationandhygienepractitionersmustacceptslippageasinevitableandrespondwithtoolsandapproachestokeepencouragingbehaviourchange.Indeed,muchlikewatersupplyandaccesstolatrines,ODFandrelatedhygienebehaviourchangemustberegardedasan‘ongoingservice’andnotjustaone-off,supply-ledeventorintervention.
Again,rolesandresponsibilitiesofkeystakeholdersneedclarificationtosupportandmanageODFstatus.Forexample,JoséaRatsirarsonhighlightedtherolethatWASHpractitionerscanrealisticallyplayinsupportingODF:
“Onceidentified,facilitatorsshouldhelpthecommunitytofinditsownsolutionratherthanbringingexternalsolutionstothem.We,asexternaltothecommunity,cannotjustsolvenorhaveallthesolutions.Theproblemcomesfromwithinthecommunityandthereforethesolutionshouldbecommunity-led,ourroleistofacilitatetheprocessoffindingtheseinternalsolutions.”
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LocalstrategiesforpreventingormitigatingslippageSeveralinterestinglocalsolutionsweresuggestedbyNanpetChuktufromhisexperiencesinNigeria–allofwhichrelatetoconsistentandclearfollow-upactivitiestomaintainchanges.Hissuggestionsincluded:
Ø WASHClinics–whichbringtogetheragroupofvillages(20-30)thathaveacommonheritageofadministrativeaffinity.Anappraisaloftheperformancesofthecommunitiesismadeandthoseperformingwellarepraised;
Ø LocalTaskGrouponSanitation–forexample,alocallybasedgroupofseniorstaffoftheLocalGovernmentAuthority,religiousleadersandtraditionalleaders.TheyhavebeentrainedontheNationalODFverificationprotocolandthecriteriaexpected.TheirroleistoconductmonthlyverificationofODFcommunitiesandhavebeenusedtoadvocateto'stubborn'orlaggingcommunities;
Ø WASHCOMS–whenacommunitybecomesODF,theyaresupportedtoformaWASHcommittee(atleast6menand6women).ThesebecomethevanguardsintheirrespectivecommunitiestosustaintheODFstatus.TheseWASHCOMSnowseektoensurethathouseholdsaresupportedtohavelatrinesthatmeettheODFcriteria,helptheagedandwidowswhootherwisecannotbuildoneforthemselves.
KamalKarandteamattheCLTSFoundationprovidedacasestudy(abridged)onKalyaniMunicipalityinWestBengal,whichwasdeclaredthefirstODFurbantowninIndiain2009.
AspartofaDFIDfundedproject,apilotwasundertakenin5slumsinKalyaniin2006atthetimewhenODwasrampantintheseslumcommunitiesandfreedistributedtoiletsremainedabandonedeverywhere.UnlikeruralCLTS,theinterventionbeganatthemunicipalcouncillevelinvolvingtheChairmanandWardCouncillorsbelongingtodifferentpoliticalparties.Oncetheneedfortheinvolvementofthelocalcommunitywasunderstoodandlocalpowerrelations/equationsweresortedout,communitytriggeringwasfacilitated.Thisinvolvedallformal/informalleadersofaparticularslum.Themunicipalitywascompletelyinvolvedinthetriggeringprocessandposttriggeringfollowup.
Within6months,these5slumsweredeclaredODF.Soon,aspillovereffectwasseeninotherneighbouringslumsaswellandby2009allofthe51slumsintheMunicipalityweredeclaredODF.ThisrapidscalingupwasonlypossiblebecauseofthecollectiveactionthatwasgeneratedwithinthecommunitiesandthenaturalleaderswhoemergedduringthisprocesswhoensuredthatalltheslumsweremadeODF.However,therateofprogressofalltheslumswasnotthesamebecauseofthevariednatureofinvolvementandcommitmentofdifferentwardcouncillors.
After6yearswesawthatthecommunitieshavemaintainedtheirODFstatusandmanyofthemhaveupgradedtheirtoiletsusingtheirownmoney.ItisimportanttonotethekeyfacilitatingrolethattheMunicipalityplayedinthisentirechangeprocess.DuringthetriggeringtheyallowedthecommunitytotaketheleadandmadesurethatthemessagesforcollectivehygienebehaviourwassustainedthroughtheHonoraryHealthWorkers(HHW)whobelongedtothecommunityinthefollowupstages.Kalyaniisaclearexamplethatforcomprehensivesanitationplanningandimplementationinurban/peri-urbanareas,thefullparticipationandengagementofallstakeholders,particularlythelocalcommunitymembersatallstagesofplanningandservicesdelivery,isessential.
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DennisAlionidiscussedalocalstrategyusedbytheWaterandSanitationPrograminUganda,whichincludedCLTStriggeringaspartofawider,holisticinitiativethatseekstoimprovetheenablingenvironmenttoo(e.g.byintroducingentrepreneursandfinancialinstitutionsintothemix“toprovideservicesandaccesstofinanceforimprovedfacilities”).Thiswasaccompaniedbydemandcreationactivities.
JoséaprovidedanexamplefromMadagascarabout‘livingbyanODFspirit’–whichoccurredwhengoodfacilitationandeffectivesupporttogenerateadeepunderstandingofthebenefitsofODFstatusledtoacommunityinBoenyRegionbeingabletorebuildtheirlatrines(ontheirown)afterapowerfulcyclone.
Slippagecriticalthreshold–impactsandmonitoringMatildaJerneckandcolleaguesattheGSFaskedwhetherthereisacriticalthresholdforwhenslippagehasanimpactonthesocialorhealthstatusofthecommunityandhowslippage,asadynamicprocess,canbemonitored.Severalcontributorsnotedthatsometypesofslippageare“morecriticalthanothersdependingonthecontext”.
Asregardshowslippagecanbemonitored,therewasagreementthatwaysofmonitoringdoneedtochangeduetothedynamicprocessofslippageandchangedbehaviours.Thereisaneedtobemoreinterrogativeandanalyticaltounderstandwhyslippagehashappenedinordertoinformthenextsteps.Plus,notallindicatorsofmeasuringODFstatusare‘equal’–theyalsomustbeunderstoodwithinthelocalcontextandresponsesmustbetailoredaccordingly.Kimberlysuggestedthat:
“ThereisastrongneedtodeveloparobustevaluationsysteminordertomaintainthestatusofanODFvillage.InadditiontosustainingtheeverydayroutineofanODFvillage,onemustevaluatethevillagetodeterminewheretheissuesareoccurringorevenwheretheyareexcelling.[…]Weproposetoaskmoredirectquestionssuchas‘Whyisthisvillagefailing?’,‘Whereisthevillagefailing’,and‘Whatisthefrequencyoffailure’.Thisway,wecanbetterpinpointthenextstepsofhowtogetthevillagebacktoODF.
ConcludingcommentsOverall,thecommentsmadeindicatedthatthereisstillalottolearnabouthowtoplanforat-scaleBHprogrammesthateffectivelylinktolocalsocialandbehaviouralnormsandinformBHtechniquesindifferentcontexts.Thediscussionprovidedanopportunitytosharesomerecentandrelevantlessonslearnedfromparticipants’differentexperiencesandprogrammes.Intermsofintegratinglearningtoimproveinterventions,bothKimberlyandKamalimpliedthatthereisaneedtocontinue‘learningbydoing’.
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DiscussioncontributorsSuvojitChattopadhyay,consultantfocusedonmonitoringandevaluationAnandShekhar,TeamLeaderatNRMC,ExecutingAgency,GlobalSanitationFundinIndiaKitchinmeBawa,WSSCCSteeringCommitteemember:Middle/Northern&WesternAfricaPeterJ.Bury,Consultant,DevelopmentProcessesAlexisD'Agostino,M&ESpecialistatJohnSnowResearchandTrainingInstituteRolandWerchota,GIZAishaHamza,Sanihygeducationinitiative(SAHEI)AnwerSahooly,SeniorInstitutionalDevelopmentConsultant(freelanceconsultantatGIZ)LalitaPulavarti,SeniorManager,ProtectsatPublicAffairsFoundationGodwin,aWASHSpecialistandConsultantHiteshChakravorty,IndiaHenrietaMutsambi,WASHManager,InstituteofWater&SanitationDevelopment(IWSD),ZimbabweNabilChemaly,GIZWaterProgramme,BurundiFranckFlachenberg,EnvironmentalHealthTechnicalAdvisor,ConcernWorldwideChhabiGoudelSamanthaFrenchJihaneRangama,TechnicalAssistant,GIZWater&SanitationProgramHannaWoodburn,TheGlobalPublic-PrivatePartnershipforHandwashing(PPPH)EdithKamundiProfHans-JoachimMosler,EawagTakudzwaNoelMushambaTomDavis,ChiefProgramOfficer,FeedtheChildrenSusanDavis,ImproveInternationalNiveditaMahotra,UrbanManagementCentre(UMC)TraceyKeatman,PartnershipsinPracticeMatildaJerneck,GlobalSanitationFundCarolienvanderVoorden,GlobalSanitationFundClaraRudholm,GlobalSanitationFundKimberlyMcLeod,MedicalCareDevelopmentInternationalAkhileshGautam,SanitationforAllinIndia,GIZNanpetChuktu,ConcernUniversal,Nigeria–GSFExecutingAgencyJonathanEkhator,ConcernUniversal,Nigeria–GSFExecutingAgencyVincentOuma,AMREFHealthAfrica,Kenya–GSFExecutingAgencyMarijnZandee,NepalBiogasPromotionAssociation,GIZAdityaSoni,UrbanManagementCentre,IndiaOrlandoHernandez, USAID-fundedWASHplusProjectTobiasOmufwoko,WSSCCNationalCoordinator,KenyaDennisAlioni,UgandaJoséaRatsirarson,MedicalCareDevelopmentInternational,MadagascarPanditThakur,NepalKamalKarandteam,CLTSFoundationMinistryofHealth,UNICEFandWSSCC/GSF,BeninRenukaBery,WASHplusProject
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Wilbur,J.andJones,H.(2014)‘Disability:MakingCLTSFullyInclusive’,FrontiersofCLTS:InnovationsandInsightsIssue3,Brighton:IDS,www.communityledtotalsanitation.org/site...ue3_Disabilities.pdf
Websites:
UNICEF:www.unicef.org/wash/index_43107.html
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3ie:http://blogs.3ieimpact.org/making-wash-behaviour-stick/
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http://www.biomedcentral.com/1471-2458/15/835
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InterestingrelatedstudybyWhaleyandWebster(2011)comparingCLTStoCommunityHealthClubsapproach:www.iwaponline.com/washdev/001/0020/0010020.pdf
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Ondefiningscaleinnutritionprojects:https://www.spring-nutrition.org/publications/briefs/defining-scale-nutrition-projects
Ongoingtoscaleonnutritionbehaviour:http://finalmile.in/behaviourarchitecture/category/social-behaviour
Onthelinkbetweenmalnourishmentlevelsandsanitationcoverage:TheResearchInstituteforCompassionateEconomics:http://riceinstitute.org/
OneffectivenessofaruralsanitationprogrammeinOdisha,India:http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(14)70307-9.pdf
OnimprovingconsumervoicesandaccountabilityinOdishaandTamilNadu,India:http://pacindia.org/uploads/default/files/publications/pdf/aaf68c1db435342f0cd6bd77fb9d31c7.PDF
OnaprivatesectorinitiativefundedbyInfosysinKarnataka,India:http://parishudh.sedam.org/