There have been some immediate responses to this theme on the WSSCC CoP! Here they are for your consideration:

Chhabi Goudel says:

I agreed with the comments made by Tracey. Behaviour change is not something that happens over the night, sustainable behaviour change is more challenge. It is possible if, the individual realise his/her dignity. So we WASH workers have to wash our minds first to give the "Dignity first" rather talking to them about us, our experience and talents..

Samantha French added:

Thanks for the thought provoking start, Tracey, I am now sat here trying to remember when and why I started washing my hands! Presumably, my mum instilled the behaviour and it was embedded at school. Now having kids and trying to ensure that they wash their hands, I have found that knowledge and understanding is important even at a young age. I don't say 'just do it', but they have been through the process of understanding why and the risks of not doing it. It then becomes routine behaviour.

However, there are times when different motivations and rewards/praise are required to encourage! Also, reflecting on when we learnt from Bangladesh and took CLTS to West Africa, we had to learn a lot about the socio-cultural context and tailor appropriately - we soon learnt that 'shame' did not motivate communities in Nigeria to change their behaviour, but rather positive motivators such as the feeling of dignity and pride. Look forward to the discussions and learning from others!

Here are the comments from one of our lead discussants this week: Henrieta Mutsambi, the WASH Manager at the Institute of Water & Sanitation Development (IWSD - see www.iwsd.co.zw/) in Zimbabwe.

From your work and perspective (and in your context), what are some of the key behaviour change techniques that work for increasing handwashing and / or increasing the use of sanitation by all household members?

Health behaviours should be engrained in one’s already existing everyday culture. Scaring tactics do not work and people including children do not believe that they will ‘die just like that’ if they do not use a toilet or wash their hands. The truth is there are more times they have failed to wash hands and they did not die. The other thing we need to consider also is that handwashing is a difficult task to achieve in most communities. BUT why are we pushing for it to happen – to avoid diarrheal and other related communicable diseases. This alone has taught us at IWSD to look at the subject in a more holistic manner. In other words, handwashing must always be discussed in relation to other hygiene enabling behaviours as I shall try to point out below.

Mainstreaming handwashing and latrine use in one’s existing culture:

• The majority of Zimbabwean people are Christians and would want to follow and do what the bible says all the time. We have used Deuteronomy 2312-14 in most rural and urban communities for sanitation uptake with great results. This was also our breakthrough point with the Apostolic Faith sects that worship in the open spaces without any sanitary facility. More work is still needed though.
• The Moslem community already believe that a person’s hands have various functions. The right hand is for eating and the left for wiping after defaecating. Generally you can’t use the left hand to greet others or to hand over something. The very fact that you perceive your left hand to be ‘unclean’ will push you to wash hands. At the same time contamination is minimised as greeting is done using the always ‘clean’ right hand. It’s an insult to hand over anything with a left hand because it’s perceived to be the ‘wiping hand’ (the African traditional culture also supports this). This can then be maximised to instil the handwashing behaviour because at least you are agreeing on something – the ‘unclean’ left hand. Further to this, one should always use the clean hand to open the toilet door, open the tap etc to avoid contamination. This can be very effective with school children.
• Another tribe in Zimbabwe, the Ndebele people are considered to be the most hygienic people. Research supports this because the only deaths that were witnessed during the 2008-2009 Cholera outbreak were actually of visitors who were coming from Harare where Cholera started off. The Ndebele do not believe in eating in public places where there are no facilities such as handwashing for example when traveling. Interestingly, this started off long back as a way of saving money but ended up being a very good hygiene practice which even the young ones are following.
• One’s social status is important to most people and so linking hygiene to status can be a hit for most communities.

By upholding the norms and values that our elders had during their time will avoid contamination in the absence of handwashing but at the same time instilling that sense of hygienic behaviour all the time.

How can we influence and transform social norms around hygiene practices so that they are sustainable?

1. Lots and lots of information, education and communication (IEC) – I have used this with my Baby-minder and my older children and I got fabulous results. I have handwashing messages and pictures literally in every other room and I have carried out secret studies of my own and I can safely say handwashing practice is now inherent in my home, but it took time.
2. Experiential learning – demonstrate to people so that they see what you technically know. For example, the snow-white towel demonstration is very effective (wiping hands with a snow white towel (1) before washing, (2) after washing with water only and (3) after washing with water and soap).
3. Use of local, influential leaders, role models, society icons, teachers (they are well respected by children) – these people appeal & echo to a larger group and this is closely linked to status and the need to belong as well.
4. Give room to people to do the unobvious, don’t scare people with cholera but instil a sense of disgust on adults… it works for school children too.
5. Be gender sensitive and apply appropriate triggering methods – people are triggered by different things, for example at public drinking point, men can easily braai meat, drink beer and use the toilet without washing their hands but most women cannot. This therefore calls for different approaches to be used.
6. Know the context and appreciate – I recently delivered twin boy and girl and I realised that it’s not that easy to wash your hands after changing babies’ nappies! I had to improvise a run-to-waste facility in the babies’ room because the bathroom is too far away, especially when both babies are crying. But I came up with a system whereby only one hand is used to wipe whilst the other one holds the baby until all the hands have been washed. As silly as it may sound, this is what all nursing mothers in my situation want to hear so that they can effectively adopt handwashing at critical times.
7. Target children to instil the culture. It’s hard to change a grown-up’s mindset!!!
8. The faecal oral route appeals more to children than adults.

Thanks, Henrieta

Just for a moment, I would like to take you back to when you first knew that you should consciously wash your hands after defecating or before eating food. You may have been 5 years old, 15 or 25 years old and there was presumably a reason for why you thought you should wash your hands. So, think back… just why did you do it? Had you been told to do so by a teacher, a family member or friend? Did someone give you an information leaflet on the health benefits? Did you simply copy others when you saw them do it? When did it become a habit that you don’t consciously even think about any more?

NB: If you can’t recall what it was like for handwashing, how about another behaviour or practice that you’ve changed in your life? Like stopping smoking or dropping litter, doing more exercise, switching lights off when you leave a room, etc.

The reason I ask these questions is to put you into the shoes of someone whose behaviour we perceive needs changing – not only for their personal benefit but also for that of a wider community. Connect with them for a moment, what does it feel like to be in their shoes? Do you like being shown, told, educated, shocked, encouraged to change your hygiene practices? What would it take to persuade you now? It would be difficult to change your mind, right?

So, this week we’re going to talk more about social and behavioural norms and dynamics that influence our hygiene practices – specifically, handwashing and the use of sanitation by all household members and all in the community.

Social norms are socially accepted or agreed values, beliefs, attitudes and behaviours – reflecting what a person considers right and expected behaviour. This is related to how people think others expect them to behave, and what most other people do. (IDS, 2015)

We’ll take a look at the processes behind behaviour change techniques; ways of understanding and addressing social behavioural norms; and how we can systematise behaviour change approaches. There will be some background documents provided on the theories behind behaviour change as well as some examples from other sectors (beyond WASH). The focus will be on sharing and learning from each others’ experiences, knowledge and expertise about behaviour change. (Next week, we will specifically go deeper into how we reach full ODF and how we deal with slippage.)

Last week (during ‘programming for scale’), several point emerged that are relevant to this week:

• Scaling up hygiene behaviour change efforts are complex due to: ‘the very nature of careful social engineering required to bring about (lasting) behaviour change seems to run contrary to some of the factors that make an intervention scalable – an ability to standardise inputs and break programme components down to easily replicable bits.’
• Hygiene education (leading to behaviour change) requires a different time frame than, say, sanitation hardware delivery, and it may not be comprehended as part of a health improvement ‘package’.
• Behaviour change programmes don’t scale up in the same way or through the same mechanisms as water and sanitation supply activities.
• We need to keep learning about how to effect systemic hygiene behaviour change in different contexts. Not because behaviour change at scale alone will mean we reach scale on access to sanitation (as Roland pointed out), but because, until recently, hygiene education was less prioritised in WASH interventions, budgets, our discourse and our mind-sets.
• We may have to accept that scaling up hygiene education may not always mean reaching 100% of the population due to population growth, people forgetting, the need for on-going education in schools and through media, etc.
• We should work more with non-traditional partners / experts perhaps – like "anthropologists, sociologists and psychologists" in sanitation programming to better understand the determinants of mass behaviour patterns and work with the private sector to learn more about innovative communication campaigns.

To get this conversation started, I asked Henrieta Mutsambi, the WASH Manager at the Institute of Water & Sanitation Development (IWSD) in Zimbabwe to share her views (see next post). Please also share your experiences and ideas on these questions:

1. From your work and perspective (and in your context), what are some of the key behaviour change techniques that work for increasing handwashing and / or increasing the use of sanitation by all household members?
2. How can we influence and transform social norms around hygiene practices so that they are sustainable? What are some of the challenges you have faced?
3. What areas do we need to learn and know more about?

Thank you also to Nabil Chemaly for his inputs from the GIZ Water Programme in Burundi and to Franck Flachenberg, Environmental Health Technical advisor at Concern Worldwide on their approach to hygiene promotion.

Thank you, Tracey

Reference:
Cavill, S. with Chambers, R. and Vernon, N. (2015) ‘Sustainability and CLTS: Taking Stock’, Frontiers of CLTS: Innovations and Insights Issue 4, Brighton: IDS
www.communityledtotalsanitation.org/reso...nd-clts-taking-stock