Behavioral Challenges and Potential Solutions to Reach Universal Sanitation Coverage by Orlando Hernandez, USAID/WASHplus Project and Senior Monitoring and Evaluation Advisor, Global Health, Population and Nutrition (GHPN), FHI 360.
The comments below are from Dr. Hernandez’s participation at the World Water Forum 2015 and then posted to the Sanitation and Water for All website.
Behavior change specialists rely on frameworks to dissect a problem and define a strategy to address it. The Water Improvement Framework (WIF), previously named the Hygiene Improvement Framework (HIF) developed in connection to USAID WASH projects some 15 years ago, is one such framework. Given its openness and comprehensiveness, the WIF has stood the test of time. Other donors and implementation agencies are thinking along the same lines as there are other similar frameworks developed by WSP, SVN, the London School of Hygiene and Tropical Medicine, among others.
The WIF is a three-legged stool which brings together: 1) supply, 2) demand, and 3) the enabling environment. It suggests that behavior change (BC) strategies are more than mere promotion, channels and messages. They bring a human dimension to the WASH sector, and when based on the WIF’s the three elements, it guides us to design, implement and evaluate WASH activities.
Behavior change frameworks require us to segment our audiences as social groups involved in development are not monolithic. One obvious breakdown in sanitation is a split between urban, peri-urban and rural dwellers. The needs, preferences, sanitation practices and certainly resources of urban, peri-urban and rural populations may be different. With growing urbanization throughout the developing world, coverage in peri-urban areas represent a challenge, especially when we think of tenants living in crowded quarters with no services.
Addressing appropriate sanitation practices in peri-urban areas will require appropriate sanitation options that would allow peri-urban residents to dispose safely of human feces. There are recent innovations which make us think about the importance of ‘human centered design’ for identifying effective supplies and products required to carry out an action. A first step in behavior change is to have the right enabling products as well as the needed access to such a product that a targeted population needs to have in order for a promoted practice to occur.
Sanivation in Kenya, for example, has developed the Blue Box. This is a container-based toilet that is placed in any room in someone’s home and serviced regularly by Sanivation’s Toilet Service Representatives. Sanivation then transforms the collected material in high-performing charcoal briquettes, which are resold on the market. Blue Box clients get a toilet and services to remove fecal matter from their homes for US$7/month.
This approach is based on research suggesting that 50% of Kenyans were planning to invest in improved sanitation, but that many of those living in peri-urban settings may be paid monthly salaries and could have no savings to construct a toilet, may have no space to build a latrine, or be moving away to another location in the near future and do not want to make permanent home sanitation improvements that would be forced to leave if and when they do move. The Blue Box toilet relies on a subscription service, has come to be perceived as a status symbol, and has a marketing strategy that relies heavily on word of mouth. There are other similar options to – dwellers: loowatt in Madagascar, Sanergy also in Kenya, etc.
We are probably all too familiar with the experience of easy latrine in Cambodia designed also using human centered design principles by iDE to come up with a toilet that responded to sanitation needs and preferences of rural residents. Three principles guided the design of these toilets as products that will be purchased by consumers to satisfy their needs. These principles can be referred to as those that meet the three A’s of a marketable product: aspirational, accessible and affordable. Cambodia was a country with 20% rural sanitation coverage when the work of IDE started.
Formative research conducted identified the characteristics of an attractive rural sanitation option. These rural consumers were interested in having a pour flush toilet with an off-set pit and a concrete superstructure that may constructed in due time once resources become available. Such a product was baptized as the easy latrine and ended up being the appropriate technological option for rural Cambodian households. Project implementers in Cambodia resolved production and supply chain issues and more quickly than expected sales and coverage increased considerably.
Universal coverage requires eliminating open defecation as a first step, and such a goal will not be achieved if open defecation is not eradicated in large countries, including India. The Government of India has a program that subsidizes latrines so households have no economic barriers to overcome in order to have latrines at home. Subsidies resolve an important barrier helping to increase access. However, access is a necessary but not a sufficient condition for use of an installed technology to use.
Access does not mean use or correct use. The Research Institute of Compassionate Economics (RICE) at Emory University, with Gates funding, has clearly demonstrated the multiple motivational barriers have to be overcome especially in Northeast India to get people that may have latrines constructed at home at the government’ s expense to accept having them installed, and also in using them.
The research conducted by RICE at Emory has demonstrated that family members in rural settings have morning walks, leaving home to breathe clean air in the woods as they wake up, and that at the end of their walk they defecate before returning home. In addition to enjoying a morning walk, there is a preference to leave their fecal matter away from home. We will be challenged to bring human centered design to address not only the specifications of on-site sanitation, but possible the characteristics of off-site sanitation.
Perhaps we need to think about the possibility of setting up public toilets in current open defecation sites. I know that off-site defecation may not be counted as part of meeting universal coverage, but we may forced to expand our definitions to take into account special circumstances affecting millions of people.
Rural sanitation offers other challenges that we should be prepared to address, even we have detected the appropriate technology as was the case in Cambodia. CLTS has been used in many countries, supported by donors and adopted by many public and private implementing agencies. However, it is an approach that is implemented in different phases including pre-triggering, triggering, adoption, sanitation facilities construction and certification.
It is certainly an approach that requires considerable institutional implementation capacity in addition to involvement of central and local government officials, community mobilizers, masons, lenders, etc. It is also an approach that moves at its own pace, village by village. The presence of multiple villages will require multiple implementation teams. I should add that participatory approaches are likely to be more effective than top down approaches that offer cookie cutter solutions.
A review of rural sanitation programs implemented in the past few years in Latin America has demonstrated that even when institutional capacity is in place, solutions exclusively from the desk of technicians that do not incorporate community members to the process of change may backfire.
Now, let me turn to a related topics: consistent use over time for all family members. Implementers of CLTS programs in multiple countries over time are beginning to generate data that helps to see what even when there is the right technology and the right institutional support to increase coverage, we may be confronted with the problem of recidivism.
Some of these implementing agencies are indicating that in some instances up to 30% of households with sanitation coverage may come back to open defecation . So, one challenge is how to make sure that family members continue to use available sanitation over the long run. We will also be concerned with the fact that the feces of all family members should be disposed of hygienically.
And in this regard, the disposal of child feces will emerge as a larger challenge than we think. Families that have access to sanitation facilities should use them to dispose of child feces. Some studies in which I have been involved open the door suggest that this is not necessarily done. If there is recidivism among adult family members, there may not be consistent hygienic disposal of the feces of younger family members, even when latrines are available.
Habit formation concepts are beginning to offer a new way of thinking regarding consistent use of a practice over time. They suggest that to instill sticky habits we must help construct routines that are driven by external cues and are repeated over time automatically.
Settings must be stable so that external cues remain constant. In addition, habit formation principles suggest that we must try to piggyback practices onto existing habits. Studying what sequence of events occur when we engage in cleaning up a child may help identify how the appropriate disposal of these feces can be integrated to such a sequence.
Universal coverage often means on-site sanitation for households. However, there is a homeless population of over a billion individuals in the world, data that was recently shared with be by a colleague from Bangladesh attending this forum.
But if the current proposal stands, the Sustainable Development Goals will define universal sanitation including both households and institutional settings, namely schools and health facilities. The WIF can be of use when deciding how to tackle behavioral issues in school populations and clients and staff at health facilities.
The health and nutrition and nutrition benefits of WASH investments may not be reached if we ignore handwashing with soap at critical junctures, before handling food and after potential contact with fecal matter. Future handwashing promotion programs targeting households should focus on having households set up permanent handwashing stations near toilets or places where food is handled, and ensuring that these stations are duly supplied with soap and water, if no tap are available.
The challenges presented by handwashing promotion are large, but it has been done for a long time now and we have different ways of tackling them. That, nevertheless, is a different discussion that we can pursue at another time.
I hope that these remarks help us have an eagle’s view at the behavior change challenges ahead of us and some potential ways to address them. We must be open to technological innovations but also to innovative behavior change approaches and new ways of tracking our achievements. I also hope that it stimulates your thinking and generates discussion.