Dear Elisabeth,

let me come in to give you an answer to your question. I am Miriam Harter, and I am a PhD candidate with Hansi and the project leader of the project “Determining the effectiveness and mode of operation of CLTS (EAWAG - Cambodia, Lao PRD, Mozambique and Ghana)”.

Your question was about the behavior change techniques we used in Ghana.

Based on the RANAS-model we identified several psycho-social factors that are relevant for latrine building. The information was gained through a broad baseline-survey in February-March last year. The data analyses revealed the following factors as relevant to discriminate doers (latrine owners) from non-doers:

1) Knowledge about diarrhea, severity (Risk factor block)
2) Beliefs about costs and benefits, feelings of being more respected when owning a latrine (Attitudes factor block)
3) Personal norm, others’ behaviour (Norm factor block)
4) Confidence in recovering (Abilities factor block)
5) Commitment, Action Planning (Self-Regulation factor block)
In addition to the RANAS-model: Communication about sanitation and Collective action (use of sanctions and contribution to a common goal)

For the intervention strategies we selected BCTs out of the canon of the RANAS-approach according to the identified psycho-social factors.

As we wanted to compare CLTS with data-driven behavior change techniques (BCTs) we identified in a first step those BCTs that are already used in the CLTS approach. We realized that quite a number of BCTs can be identified and account for some of the psycho-social factors relevant for latrine construction. That is why we included CLTS as implemented traditionally by our partnering NGO in our intervention program.

We developed three different intervention strategies:

1. CLTS traditional, how it was already implemented by our partnering NGO
This included a community meeting with the typical community mapping and the shit flow diagram and information about diarrhea. Furthermore explanation on latrine construction and costs are part of the CLTS approach implemented by our partnering NGO, as well as the implementation of by-laws and sanctions for non-compliers.
--> Factors to be tackled by this intervention (collection of different BCTs): Health Knowledge, Severity, social context (increasing the contribution towards a common goal). And in addition to the RANAS-model the factor communication about sanitation that was found to be relevant for latrine construction

2. Household action planning (addition to CLTS)
On an individual household level a detailed action plan about how, when and where to construct a latrine. For every step of the construction the needed material was depicted and each step was time-bound in agreement with the household. The household was instructed to use the action plan as a monitoring tool and post it on an visible place in the compound. They were instructed to sign their individual action plan.
--> Factors to be tackled by this BCT: Action planning, Beliefs about costs and benefits, Confidence in Recovery

3. Public commitment (addition to CLTS)
After the community meeting (CLTS-meeting) the individuals who voluntary agreed to construct a latrine were invited to stand in front of the community and promise to the others to construct a latrine for their household. Each household that promised to construct a latrine was given a sticker to post it visibly on the wall and to show their commitment in public. When the household completed the latrine they were given a flag to hang it at the latrine.
--> Factors to be tackled by this BCTs: feelings (respect of others), personal importance, others’ behavior and commitment

That resulted in our final intervention implementation design:
1. CLTS traditional
2. CLTS traditional & Action Planning
3. CLTS traditional & Public Commitment
4. CLTS traditional & Action Planning & Public Commitment
5. Control Group

If you need more information, let me know.

Best,
Miriam

Dear Hansi,

I clicked through the presentation that you had posted on 6 July 2017 and found it excellent! You are performing here exactly the kind of scientific research that is sorely needed in our sector! The presentation is clear, full of detail and interesting to read.

These are your research questions that you go through in the presentation:

- Research question 1: How successful is CLTS?
- Research question 2: Which contextual and psychosocial factors differentiate between latrine builders and nonbuilders?
- Research question 3: Which behavioral factors are related to CLTS which in turn differentiate between builders and non-builders?
- Research question 4: How are the elements of CLTS perceived?
- Research question 5: How can CLTS be improved? New interventions for CLTS in Ghana

The preliminary conclusions from your last slide:

1. CLTS is working quite well by triggering an intensive social process in
communities with positive preconditions (social capital)
2. The RANAS behavioral factors can explain latrine building quite well
(the difference between builders and non-builders)
3. CLTS is targeting the relevant behavioral factors and this might be the
reason for success
4. Eliciting emotions is important for CLTS, however the adequate
degree of shame and disgust has to be known to not induce refusal of
CLTS elements
5. CLTS may be improved by adding planning and social interventions
from the RANAS catalog of behavior change techniques (this has to
be proven)

++++++++++++++

Could you explain a bit more your Point 5? Which behavior change techniques are particularly promising in this respect?

And apart from publishing in journals what else is planned to put your research results into practice? E.g. have you been in contact with CLTS Foundation in the UK (Petra Bongartz) - do they have an interest in publishing this in their channels of communication?

And I look forward to using your work soon to update the Wikipedia article on CLTS (en.wikipedia.org/wiki/Community-led_total_sanitation) and also the Wikipedia article on behavior change: en.wikipedia.org/wiki/Behavior_change_(public_health).
Is the article on behavior change methods any good? en.wikipedia.org/wiki/Behavior_change_method
There is also one about behavior change theories (no mention of RANAS or Mosler in that article): en.wikipedia.org/wiki/Behavioural_change_theories

Is there by any chance someone in your team who could be delegated to help with this Wikipedia kind of work - an important public education tool?

Regards,
Elisabeth

Here an update on our project "Determining the effectiveness and mode of operation of CLTS (EAWAG - Cambodia, Lao PRD, Mozambique and Ghana)":

We have completed the cross-sectional surveys in Cambodia and in Mozambique. Two articles about the Mozambique study were submitted to scientific journals. As soon as they are accepted I will post them here. Meanwhile I post a presentation about preliminary results in a document.
The project has suffered from delays which means that the results of the midline survey of the CLTS experiment in Ghana will be presented in a few months.

Best, Hans Mosler

Here is a half page summary about the current status of this project in a recent report by the BMGF called "Building Demand for Sanitation - A 2015 Portfolio Update and Overview" (available here in the SuSanA library; Roshan has made a post about this report here: forum.susana.org/forum/categories/139-gr...etails-for-22-grants)

As this grant is still in its early days, the write-up is not adding much new compared to the description above on this thread. Nevertheless, I thought it could be useful to remind ourselves of this ongoing work on CLTS research.


From this pdf file (file is attached below):

++++++++

Research Focus:

To analyze the behavior change approaches used by CLTS and
community ODF adoption processes. The research will attempt
to determine how different elements of CLTS affect behavior,
and whether there are elements which have counter-effects
on individuals or social systems. The study will identify the
psychological determinants of behavior change triggered by the
CLTS activities. In addition, the study seeks to identify which
are the best combination of CLTS elements to attain an ODF
community, and to unpack the ODF adoption process including
assessing which community members are ending OD first, who
is doing so last, and why. Finally, the identified combinations
of CLTS elements will be compared to a data-driven behavior
change strategy.

Methodology:

Pre-surveys will be conducted in 3 countries (Cambodia, Lao
PDR, and Mozambique) where CLTS has been implemented
(600 households in each country). The main study to follow will
be conducted in Ghana, as the research component of a large
CLTS implementation program funded by USAID. The study
includes face-to-face interviews in 3,125 randomly selected
households using quantitative, structured interviews on three
key behaviors: OD, latrine construction, and latrine use; as
well as behavioral determinants. Spot checks will be conducted
regarding OD within households and at the village level.
The pre-surveys started in March 2015, and the main research
in Ghana will follow—starting with a baseline survey in
October 2015.

++++++++++

Documents in the SuSanA library: www.susana.org/en/resources/library/details/2206

Regards,
Elisabeth

Dear Kim, you request is very qualified. However, each research project has its limitations, mainly time restrictions, meaning that a 12 months period is not the optimal but the maximal what we can get with the existing restrictions.

Thanks Hansi for sharing the design of your interesting study.
One comment on your overall objectives/results: "e) how societal processes should be facilitated for communities to reach the ODF status" should be complemented with "...and to maintain ODF status" as this is, to my understanding the key objective/challenges. A related question would be whether your finale survey, 12 months after baseline allows for sufficient time to really assess sustainability issues of the possible current ODF status.

I found the attached poster quite useful in understanding better what this project by Hansi Mosler (Determining the effectiveness and mode of operation of CLTS: The DEMO-CLTS study) is all about. The poster contains a nice graphical presentation of the methodology.

It also briefly explains the RANAS model (Risk, Attitude, Norms, Ability & Self-Regulation):
•The RANAS model is a conceptual framework to explain change in hygiene and sanitation behaviour and a guideline to design and evaluate behaviour change campaigns.
•The RANAS model distinguishes 16 factors in five factor blocks that should be positive towards the target behaviour.
•The Model offers sample items for structured questionnaires and intervention techniques targeting the determined factors

If you are interested in the science behind behaviour change and CLTS, do take a quick look at this poster.

Dear all,

I am happy to tell you about a new 3-year grant researching CLTS (community-led total sanitation) funded by the Bill & Melinda Gates Foundation which I am leading. I am sharing the details of our project with you below. If you have any questions or comments about it, please put them in this thread by replying to this post.


Title of grant: Determining the effectiveness and mode of operation of CLTS: The DEMO-CLTS study

(CLTS stands for community-led total sanitation)

• Name of lead organization: Eawag, Environmental and Health Psychology
• Primary contact at lead organization: Prof. Dr. Hans-Joachim Mosler,
• Grantee location: Dübendorf near Zürich in Switzerland
• Developing country where the research is being tested: Cambodia, Lao PRD, Mozambique and Ghana
• Start and end date: Nov. 2014 - Oct.2017
• Grant type: (e.g. Global Challenges Explorations, Reinvent the Toilet Challenge, Other): Other
• Grant size: USD 641,809 (as per BMGF grant database )

Goal: The study’s overall goal is to improve the behavioral change strategies used to eliminate OD.

Objectives:
in the first phase, the elements fostering or constraining the success of CLTS will be identified.
In the second phase, a cluster-randomized controlled trial will be conducted to test variations of CLTS with or without these elements; against one another; and against an evidence-based, behavioral change approach (the RANAS Model).

Research or implementation partners: Plan International with its regional offices; USAID is a partner in Ghana where they will finance the implementation

Links, further readings – results to date:
Documents in the SuSanA library: www.susana.org/en/resources/library/details/2206

Results will also be available on the Eawag homepage of Environmental and Health Psychology (and in this thread) (www.eawag.ch/forschung/ess/gruppen/ehpsy...ch/projects/index_EN)

Short description of the project:

This study will reveal the effectiveness and mode of operation of the community-led total sanitation (CLTS) intervention to decrease the incidence of open defecation (OD). In particular, it will determine which elements of CLTS are highly efficient in decreasing OD, which elements have no effect, which hinder the decrease of OD, and which are the most efficient in supporting communities in the attainment of OD-free (ODF) status. Additionally, the mode of functioning for CLTS will be investigated, and an evidence-based, behavioral change approach (i.e., the Risk, Attitude, Norms, Ability, Self-Regulation [RANAS] Model) will be contrasted with CLTS to disclose the most effective method of decreasing OD through behavioral change.

In the first phase of the project, an ad hoc survey will be conducted in 90 communities of 20 households each (N=1800), located in Cambodia, Lao PDR and Mozambique where CLTS has been implemented more or less successfully. Several interesting variations of CLTS will emerge from this survey and will be tested in a cluster-randomized controlled trial against one another, against the RANAS approach, and against a control arm. Therefore, baseline (before), midline (4 months after), and endline (12 months after) surveys will be carried out in 25 communities, each comprising 25 households (adjusting for panel dropout), in each of the five intervention arms within one country (N=3125). This trial will reveal which behavioral change approach is most efficient and how well the strategies are working. The study will improve behavioral change practice to foster the fight against OD.

Study Design

The study’s overall goal is to improve the behavioral change strategies used to eliminate OD. Therefore, in the first phase, the elements fostering or constraining the success of CLTS will be identified. In the second phase, a cluster-randomized controlled trial will be conducted to test variations of CLTS with or without these elements; against one another; and against an evidence-based, behavioral change approach (the RANAS Model).

In the first phase, 30 communities each in three different countries with different levels of success in CLTS and with various versions (e.g., “light” CLTS) will be analyzed ex-post. The 30 communities will necessary arrive at conclusions that are generalizable from the household level to the community level. Assuming moderate between-cluster variance in effects (intraclass correlation = 0.4), 30 clusters will allow for the detection of small effects of the CLTS elements on OD, given a sample size of 20 households per community and a power of 0.8. This research will be conducted in three countries that differ in CLTS-relevant factors (e.g., how the population deals with shame) and in which the USAID has implemented CLTS extensively, but not for a time period exceeding one year prior to the study. This approach will lead to more culturally robust conclusions.

In each of the 90 communities, the members of 20 randomly selected households (Total N = 1800) will be interviewed regarding their perceptions regarding CLTS elements, the use and cleaning of latrines, the respective behavioral determinants, etc. Regarding social dynamics, the study will identify the first households to abandon OD, the last ones to do so, which members of society promoted OD elimination, which members were hesitant, etc. The ODF status will be measured through self-reporting and observation methods. On the individual level, toilet use will be observed, whereas, on the community level, a reliable method will be developed, using a random sample of observation points. Statistical multilevel modeling will reveal which individuals, in combination with which social factors, favor an ODF community or hinder a community from becoming one. The analysis will also indicate which CLTS elements are important for success, as well as their respective significance levels. These results will serve as the basis for conducting the next phase.

In the second phase, a cluster-randomized controlled trial will be developed in Ghana with different intervention arms. To detect a 20% difference in OD rates between each intervention arm and the control arm (Cohen’s d = 0.63), each arm will consist of 25 communities. This research will take place in Ghana, since the USAID is currently implementing CLTS at scale and has agreed to apply various CLTS versions, as well as an evidence-based behavioral change strategy. If possible, the study will also be carried out in a second country with a different cultural background.

First, a baseline survey will be conducted in all communities for which defecation habits will be recorded (i.e., reported and observed), and social interactions, social institutions, and existing social networks will be identified. At the individual level, face-to-face interviews will be conducted with 25 caretakers of children (adjusting for a 25% panel dropout) in each of the 25 randomly selected communities in each intervention arm in order to assess behavioral determinants using the RANAS model. Multilevel modeling of OD behavior will reveal which of the behavioral determinants and social factors are most significant for directing OD behavior. These behavioral and social determinants will be targeted within the experimental arm, employing an evidence-based behavioral change strategy.

Following the baseline survey, the 25 communities will each be randomly assigned to the following four intervention arms and one control arm, respectively:
1) full CLTS according to the handbook,
2) CLTS variation A,
3) CLTS variation B,
4) an evidence-based behavioral change strategy, and
5) control without any behavioral change measures.

Variations A and B of CLTS will be determined by the results of the post-hoc survey of the first phase. The evidence-based behavioral change strategy will be established using the results of the baseline survey of the second phase. The implementation process of CLTS will be standardized and recorded in detail, since it is well known that the facilitator’s attitude and approach play a key role in success (CLTS Handbook, p. 22). In all selected communities, ongoing social processes will be monitored via weekly cell phone interviews (if feasible) with key persons in the communities (10 persons in each community), and the progress toward reaching the ODF status will be monitored weekly until four months after the implementation of CLTS. To control for reactivity, this step will also be performed in the control arm. Four months after CLTS, one mid-term survey will be conducted with the same participants as in the baseline to reveal changes in behaviors and behavioral determinants. An end-term survey will be conducted 12 months after the interventions to reveal the sustainability of the behavioral changes.

In summary, the surveys in the first phase will reveal the first evidence of the individual and social factors related to toilet use and the attainment of the ODF status, as well as provide hypotheses regarding the effectiveness of specific CLTS elements. The cluster-randomized controlled trial will generate data from 125 communities and 3,125 individuals through three surveys (baseline, 4 months, and 12 months after CLTS), as well as weekly monitoring data over a four-month period. These data will reveal the differential effectiveness of the various versions of CLTS, as well as that between CLTS and an evidence-based behavioral change strategy. Data from the monitoring will disclose the processes of both individual and societal behavioral changes.

Overall, the results will show a) the mode of functioning of CLTS, b) the most effective CLTS strategy, c) how CLTS can be optimized, d) whether or not CLTS is the best behavioral change strategy, and e) how societal processes should be facilitated for communities to reach the ODF status.

Ethical approval for the entire study will be requested from the Ethical Board of the Department of Psychology at the University of Zurich. Ethical approval from the respective countries will be sought as required. Informed consent will be solicited from each interviewee and from the authorities of each community.


Current state of affairs: Actually the questionnaire was finalized and is ready to be implemented in Cambodia, the first study region. The survey will start 16th of march with 600 households in Siam Reap and Kampong Cham. Next steps are the pre-phase surveys in Lao PDR and Mozambique.

Biggest successes so far: Having established a stable contact with local project partners and being ready to start the first phase in Cambodia, Lao PDR and Mozambique

Main challenges / frustration: Having to fight with the floods burdening our partners in Mozambique and therefore the postponement of the first survey in their region.

I am also attaching the same information as a pdf file below.


_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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/forschung/ess/gruppen/ehpsy/index_EN