Sustainability for behaviour change - introduction, invitation and questions

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  • TraceyKeatman
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Sustainability for behaviour change - introduction, invitation and questions

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
Tracey Keatman
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Re: Sustainability for behaviour change - introduction, invitation and questions

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
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Re: Sustainability for behaviour change - introduction, invitation and questions

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!
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Re: Sustainability for behaviour change - introduction, invitation and questions

We've also received a couple more comments today on the WSSCC CoP about Franck's contribution at: forum.susana.org/forum/categories/212-th...trategy-for-hp#15138

Jihane Rangama noted:

I couldn't agree more with Frank's comment. I would add that in a lot of WASH programmes, especially in Western Africa (and Burkina Faso, where I work), hygiene promotion activities such as awareness door-to-door, are performed by local volunteers (members of local women's associations for example). Those volunteers first receive a basic training on hygiene promotion, and then we expect from them to dedicate a few hours a week for several months to deliver hygiene promotion messages to the community. However, many projects feedbacks showed that the volunteers's motivation to perform the HP activities decreased pretty quickly, and the results in terms of behaviour change interventions were not as good as expected. In conclusion, I strongly believe that one of a key to conceive an efficient and sustainable behaviour change campaign is to rely on paid professional workers dedicated to one targeted behaviour.

Samantha French added:

Franck, your comments and Strategy make perfect sense. I think a multi pronged approach is critical as people respond in very different ways. What you have said about igniting an emotional response that trigger the desire for change reminds me of the debates we were having at WaterAid when developing the new global strategy, in which hygiene behaviour change features as a global aim. The demand and desire needs to be created, presumably through the different approaches you have mentioned. Cross sector integration is also key so that schools, health centres, midwives etc all reinforce the same messages.
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Re: Sustainability for behaviour change - introduction, invitation and questions

Thanks, Tracey, for your work kicking off this conversation.

I just got back to D.C. after a week in New York for meetings around the UN General Assembly. Many of the events I attended were on implementing the 17 new Global Goals, and when behavior change was mentioned as being key to achieving these goals responses were often abstract. I don't need to tell you all that it is clear just how challenging behavior change is!

And yet, if we hope to have sustainability in our programs, and indeed make a dent on achieving the Global Goals, we must address actually changing behavior.

Through our Handwashing Behavior Change Think Tanks, the Global Public-Private Partnership for Handwashing works to take stock of the best, articulate the gaps, and identify the way forward for hygiene behavior change. Our last Think Tank, held at AfricaSan4 in Dakar, Senegal looked at three big ideas in hygiene behavior change: emotional motivators, behavioral settings, and the science of habit. You can find a brief summary here: globalhandwashing.org/learn/key-topics/think-tank/ . I think that the lessons we have learned in each of these areas are applicable to other categories of behavior change. Would you agree?
Hanna Woodburn
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Re: Sustainability for behaviour change - introduction, invitation and questions

As stated by WASHHanna motivators are important in behaviour change, applying a mix of different drivers to motivate individuals or even communities to change their behaviours may yield positive results. For example use of shame and affiliation in triggering elimination of open defecation is useful while at the same time incorporating the social cultural triggers in the community.

While working with project officers in Papua New Guinea we also learnt that behaviour change is difficult if not accompanied by infrastructure. Promoting hand washing with water and soap in a community that still uses traditional sources of water such as dug wells that are seasonal, may not be effective because most people will prioritise other household needs. Also, communities that practice open defecation do not practice hand washing because the bushes are located far from the same traditional water sources.

Another Challenge, many local NGO interventions are project based (1 to 2 years) which limits the amount of time spent in the communities. Monitoring behaviour change becomes constrained by resources and project implementation activities/steps/cycle.

Maybe behaviour change should also apply to those responsible for WASH interventions - state and non state actors, to change the way we engage with communities in addition to focusing on the individual practising the risky behaviour
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Re: Creativity in Behavior change workshop (London, UK)

I attended the workshop "Creativity in Behavior Change"* and gave the attached presentation with the title “The RANAS Framework for Systematic Behavior Change”.

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It was interesting to see how other researchers as well as practitioners design their interventions and this not only in the WASH sector. We saw several videos of differing appealing degree. A number of specialists from creative agencies presented their approach to design interventions. It seems to be necessary that researchers and creative agencies cooperate in designing effective interventions however it remains undefined how this should be done.

* The Workshop took plane on 23 Sept. 2015 in London UK
Organised by Environmental Health Group - Faculty of Infectious and Tropical Diseases
London School of Hygiene and Tropical Medicine
www.ehg.lshtm.ac.uk


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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Prof. Dr. phil. et dipl. zool.
Hans-Joachim Mosler
Eawag, Environmental Social Sciences
Environmental and Health Psychology
Überlandstrasse 133
CH-8600 Dübendorf / Switzerland

www.eawag.ch/en/department/ess/main-focu...th-psychology-ehpsy/

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Re: Creativity in Behavior change workshop (London, UK)

Thanks for the inputs and your presentation Hans. What I really appreciate about your analysis is the systematic mapping of potential behavioural determinants (based on human psychology) and how they can be practically linked to specific behaviour change technologies. So then, practitioners would be able to develop a tailored, context-specific approach.

Although, as you pointed out, designing those approaches could be better done by engaging with creative agencies - who would also have to understand the context and audience. Regarding your point on how this collaboration could / should be done, several companies (of course, UNILEVER) come to mind that have approached changing hygiene behaviours on a large scale, with the support of such agencies for sure (for example, see www.unilever.com/sustainable-living/the-.../health-and-hygiene/ ).

Clearly, there's a (potentially controversial) question here about how we engage with the private sector - whether big companies or creative marketing agencies. Beyond that however, what seems important for me is to better understand and learn from their experiences and expertise on the basic mechanisms or structures behind the design of large scale behaviour change media campaigns.*(Ref below) So that those design principles are coherently addressed in the design of our programmes and complement whatever is happening on the ground on personal health education and follow-up.

On the WSSCC CoP, Hanna Woodburn shared with us a blog on what makes WASH behaviours stick ( blogs.3ieimpact.org/making-wash-behaviour-stick/ ). It also links to a 3ie-supported systematic review (available at: www.3ieimpact.org/publications/systemati...ic-review-summary-2/ ) which found that:

... frequent, personal contact with a health promoter over a period of time is associated with long-term behaviour change. The review suggests that personal follow-up in conjunction with other measures like mass media advertisements or group meetings may further increase sustained adoption.


Having a complementary approach (mass media plus local, sufficiently long-termed support and follow-up) can clearly reap rewards. My question is, how to we systematically plan for that and deliver it in a project or programme cycle? Hygiene behaviour change rarely seems to be elevated to this systematic planning status in WASH programmes - despite our recognition of its importance. It also requires us to work in partnership with others that we may not usually engage with - and we all know how challenging it is to work in partnership :-).

All this to say that we clearly need to challenge and change our own behaviours and norms that influence our working practices too!

Any thoughts you or colleagues have on this would be welcomed - especially those with examples of where these types of multi-pronged approaches have seen success.

Thanks everyone, Tracey

* UNILEVER design advice for mass media campaigns: www.unilever.com/Images/slp_5-Levers-for...ge_tcm244-414399.pdf
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Re: Inputs from the WSSCC LinkedIn CoP

Hi everyone, there have been additional inputs into this discussion from the WSSCC CoP. I've copied the messages for your consideration:

From Takudzwa Noel Mushamba:

Thank you Tracey for the insightful discussion. I am a Zimbabwean graduate student based in Turkey. I am an engineer by profession I worked in Zimbabwe and Namibia. I am not an expert in behaviour change regardless associating and working in various WASH projects. I am going to comment as an engineer and a person who grew up in a peri urban area (Epworth, no piped water, poverty etc) I am sure you get the picture. As human beings we are programmed or so I believe to behave in a certain manner unless there is a strong reason to change that pattern. Clearly most people have knowledge about hand washing and the risk associated with not doing so. But underlying factors such as the financial status of a household always play a part:

  1. Convenience - despite knowing all the risks involved with unclean hands most people are not willing to go through the process of going to get water from a few kilometres away hence i firmly believe a person with piped water in the house has "better chances" of changing or adopting hand washing for example.

  2. Absence of cases or low prevalence of water and sanitation diseases is not necessarily and indicator of "improved behaviour". I am sure we all understand the epidemiological triangle ( www.cdc.gov/bam/teachers/documents/epi_1_triangle.pdf ) lets assume I do not wash my hands when I am in Europe. I am sure I have less chances of contracting a disease related to WatSan because of the environment while at the same time it is easy to adopt hand washing because of the convenience and access. I think we are more a product of the environment that what people tell us.
The same message means different things to two people. To one it means open the tap and a hand sanitizer and to another it means buy extra soap travel to a borehole 8 km away and get an extra bucket of water and wash before you eat. Infrastructure plays a huge role not only in reducing exposure but also in fostering new behaviour. Thank you[/i]

And from Tom Davis who comments on Jihane's earlier comment:

I think the focus on using paid professionals for health promotion, Jihane, is unfounded. See this paper where we found that projects using Care Groups had double the adoption of HWWS as projects that did not use Care Groups. Care Groups rely on volunteers. www.biomedcentral.com/1471-2458/15/835

Also see the different determinants found for the 18 Barrier Analysis studies on HWWS shown on the Food Security and Nutrition Network's Behavior Bank. www.fsnnetwork.org/behavior-bank .
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Re: Sustainability for behaviour change - introduction, invitation and questions

Désolé pour le retard de partager l'information en français ...

Pour un changement durable des comportements – Introduction, invitation et questions

Je voudrais vous ramener, juste pour un moment, à la première fois que vous avez pris conscience que vous deviez vous laver les mains avant de manger ou après avoir déféqué. Vous aviez peut-être 5 ans, 15 ans ou 25 ans et on peut supposer qu’une raison vous a poussé à le faire. Alors, réfléchissez... pourquoi l’avez-vous fait ? Un professeur, un membre de la famille ou un ami vous a-t-il dit de le faire ? Quelqu’un vous a-t-il remis un fascicule sur les avantages que cela représentait pour votre santé ? Avez-vous simplement reproduit ce que d’autres faisaient ? Quand est-ce devenu un automatisme ?

N. B. Si vous n’avez aucun souvenir à ce sujet, essayez de penser à un autre comportement ou à une autre pratique que vous avez modifiés dans votre vie. Par exemple, arrêter de fumer, mettre les déchets à la poubelle, faire plus de sport, éteindre la lumière lorsque vous quittez une pièce, etc.

La raison pour laquelle je vous pose ces questions est que je voudrais que vous vous mettiez à la place de quelqu’un dont vous pensez que le comportement doit changer ; pas uniquement dans son intérêt personnel, mais aussi dans celui de la communauté. Mettez-vous à la place de cette personne quelques minutes, comment vous sentiriez-vous ? Comment aimeriez-vous que l’on communique avec vous : par les gestes, la parole, l’éducation ? Par la provocation ou les encouragements ? Comment pourrait-on vous convaincre en cet instant précis ? Il serait difficile de vous faire changer d’avis, n’est-ce pas ?

Cette semaine, nous parlerons des dynamiques ainsi que des normes sociales et comportementales qui influencent nos pratiques en matière d’hygiène, en particulier le lavage des mains et l’utilisation d’installations sanitaires par tous les membres des ménages et par l’ensemble de la communauté.

Les normes sociales sont des valeurs, des croyances, des attitudes et des comportements socialement acceptés ou approuvés – qui traduisent ce qu’une personne considère comme étant le comportement correct que l’on attend d’elle. Cette notion est liée à l’idée que les gens se font du comportement que l’on attend d’eux et à ce que font la plupart des autres gens. (IDS, 2015).

Nous aborderons les processus qui sous-tendent les techniques de changement de comportement, les différentes façons d’appréhender et de faire évoluer les normes sociales et comportementales, ainsi que la façon dont nous pouvons systématiser les approches de changement de comportement. Nous fournirons des documents de référence sur les théories qui sous-tendent le changement de comportement, ainsi que des exemples tirés d’autres secteurs (que WASH). Enfin, nous nous attacherons à partager et à tirer les enseignements des expériences, des connaissances et de l’expertise de chacune et chacun en matière de changement de comportement. (La semaine prochaine, nous étudierons plus en détail les solutions qui s’offrent à nous pour mettre fin à la défécation à l’air libre et empêcher le relâchement.)

Pour entamer la discussion, j’ai demandé à Henrieta Mutsambi, responsable du programme WASH à l’Institut pour le développement de l’eau et de l’assainissement (Institute of Water & Sanitation Development – IWSD) au Zimbabwe de nous faire part de son point de vue (voir billet suivant). Je vous invite également à partager vos expériences et vos idées sur les questions suivantes :

1. Selon vous et d’après votre expérience (et le contexte dans lequel vous travaillez), quelles sont les principales techniques de changement de comportement qui fonctionnent pour intensifier la pratique du lavage des mains et/ou l’utilisation d’installations sanitaires par tous les membres des ménages ?

2. Comment pouvons-nous influencer et modifier de façon durable les normes sociales liées à l’hygiène ? À quelles difficultés avez-vous dû faire face ?

3. Sur quels domaines devons-nous nous pencher et lesquels devons-nous approfondir ?

Je remercie également les membres du Forum SuSanA d’avoir partagé leur approche de la promotion de l’hygiène : Nabil Chemaly pour sa contribution sur le Programme pour l’eau du GIZ au Burundi, ainsi que Franck Flachenberg, conseiller technique en hygiène du milieu chez Concern Worldwide.

Merci.

Tracey

Référence :

Cavill, S. avec Chambers, R. et Vernon, N. (2015) « Durabilité et ATPC : État des lieux », Aux Frontières de l’ATPC : Innovations et Impressions n° 4, Brighton : IDS.

www.communityledtotalsanitation.org/reso...t-atpc-tat-des-lieux

www.communityledtotalsanitation.org/site...%C3%A9_et_ATPC_0.pdf
Tracey Keatman
PiP – Senior Consultant
Partnerships in Practice Ltd.
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Site: www.partnershipsinpractice.co.uk
Twitter: @pipunltd
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  • Improvedavis
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Re: Creativity in Behavior change workshop (London, UK)

Hans - thanks for sharing this presentation. I think it's similar to one I saw you present at the Oklahoma University WaTER conference. Your conclusion is to change behavior, use psychology. I remember thinking then, as I did reading through this presentation - governments and WASH NGOs need new types of people! Or at least new partners.

I'm curious how many WASH implementing organizations have this kind of skill on staff?
Susan Davis
Executive Director
Improve International
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Re: Sustainability for behaviour change - introduction, invitation and questions

I know I'm a bit late to this conversation but I read an interesting related study by Whaley & Webster - they compared CLTS to Community Health Clubs approach
www.iwaponline.com/washdev/001/0020/0010020.pdf

"Whilst both approaches effectively encouraged measures that combat open defecation, only health clubs witnessed a significant increase in the adoption of hand washing. However, CLTS proved more effective in promoting latrine construction, suggesting that the emphasis the CHCs place on hygiene practices such as hand washing needs to be coupled with an
even stronger focus on the issue of sanitation brought by CLTS."
Susan Davis
Executive Director
Improve International
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