Behaviour Change Research in WASH and Lessons for Practice Depinder Kapur India WASH Forum 18 th Feb 2015

Sanitation trend in India Sanitation coverage increased 1% pa since 1980, irrespective of high subsidy(TSC in early 1989s), low subsidy(since 1999 sector reform) and incentive(NGP, 2003) based sanitation promotion. Peoples preference for good quality toilet construction, septic tanks not pit latrines in rural areas. Under spending on CRSP/TSC/NBA. Construction focus not promotional work.

Hygiene and Sanitation Research: some directions

Behaviours: Basis of analysis Qualitative research. Listing out key determinants of hygiene behaviours and assess responses across 4 districts More than one factor could determine a particular behaviour. Similarities and Differences when observed in more than two districts, then considered as similarities When observed in two or less districts, then considered as differences

WASH Health Impacts: Trends Inadequate access to water and sanitation accounts for only 0.9% of the global burden of disease Globally child mortality has halved/come down, life expectancy has increased with non communicable diseases becoming more dominant Child deaths from diarrhea fallen from 2 million a year in 1990s to less than 700,000 a year DALYs lost due to inadequate access to water and sanitation halved since 1990

What do the trends tell Difficult to assess the relative contribution of a single risk factor to global burden of disease Measuring attributing of specific WASH interventions (sanitation, hand washing, etc.) towards health outcomes (diarrhea reduction) vis a vis no intervention – very difficult. Yet there is no denying that clean environment and personal hygiene contribute to good health and reduction in diarrhea, serious infections, disease and food absorption. WASH health impacts research : specially hygiene health impact research: a priority for commercial sector, linked to product promotion, can sometimes prioritise one hygiene intervention over the others Core focus on safe drinking water and basic sanitation can get sidelined

Reasons for disuse of toilet; 2010 study Poor unfinished installation(31%) Poor construction(26%) – blockage, pan chocked, poor disposal arrangement, etc. No superstructure(14%) Wrong location(5%) Lack of water(9%) Lack of behaviour change (18%)

Formative Research in Sanitation and Hygiene; Key Findings Bihar 2011

RESEARCH TOPICS 1.Demand for and use of toilets leading to open defecation free environment 2.Personal hygiene and hand washing with soap or ash at critical times 3.Safe water handling, maintenance of water sources and water quality monitoring 4.Safe disposal of child excreta and other solid wastes Districts covered: 1.Gaya – High Proportion of Mahadalit Population 2.Madhepura – Kosi Region 3.Sitamarhi – North Bihar 4.Vaishali – Integrated District

FR STUDY FINDINGS SANITATION – TOILET USAGE

Sanitation: Status, Issues Progress in breaking resistance towards building and using toilets. Instances of people building toilets on their own, as well as repairing TSC toilets that have been damaged – are there but few Despite the high level of awareness, the vast majority of men and children continue to defecate in the open.

Sanitation: Knowledge & Awareness

Sanitation: Barriers to toilet Use

Low Toilet Usage: some reasons Contractor led construction of toilets is leading to poor quality construction, design not being suitable, bad location Water What appears as technical failure is a result of lack of engagement of households in the construction process Most of the toilets are not being kept clean. Behavioural issues

STUDY FINDINGS Hand washing with soap at critical times

Hand Washing: Status and Issues High awareness but low practice of hand washing with soap at critical times Hand washing with soap, before eating is lower than after defecation Hand washing after defection is done with mud Ash is not a preferred medium for hand washing after defecation or before eating.

Hand Washing: Status and Issues Few women reported using ash for hand washing after defecation Children seldom washed hands with soap after defecation and before eating. Not enough being done at home and in school to address this behavior Bad Smell: most important Motivation for hand washing. Health not a prime motivator

Hand Washing Behaviour – Deeper Barriers For those who work in the fields, doing manual labour, improved personal hygiene had a distinct class and caste association. Personal hygiene including wearing clean clothes and washing hands with soap - seen as a behaviour that only the rich and those who do not perform manual labour, can practice Well entrenched hierarchical social status : improved personal hygiene or looking clean for the marginalised is percieved as coming into conflict with status quo Gender dimension – toilet decision and O&M Minority muslim community, the fear that there is pig fat in soap, is deterring soap usage (only in a few villages this was observed).

Other studies in WASH Drinking Water Safety

Drinking Water Safety: Key Observations and Behaviours Very low cases of diarrhea in urban slums of Delhi, serious infections are higher. Traditional practices of household water safety breaking down Cost of boiling water, space, risks Convenience matters Chlorine tablets, Sodis – not preferred – taste Water filters not preferred because of poor O&M Infrastructure based water treatment options preferred Bio sand filters – West Bengal, Jharkhand tribal areas RO water – Chennai slums and urban areas Preference for RO Water in terms of TASTE, preferred over other drinking water – Chennai, Warrangal rural areas

BCC in WASH: Where should we start from and end?

Caste dimension (Impurity, Dirty, Occupational) of sanitation and hygiene in India Manual scavenging and all other occupations dealing with cleaning – lowest social status Missing WASH messages in BCC campaigns Gender sensitive messaging Norms and entitlements Identifying peoples preferences(and reasons) for toilets and safe water, deciding on programming priorities, a BCC campaign that identifies barriers and deeper motivations. eg. Septic tank systems vs pit latrines Filters vs RO systems Monitoring behaviours and not health outcomes ? SHEWA-B project in Bangladesh showed no significant improvement in health outcomes(reduction in diarrheal incidence) of integrated WASH programming at scale Should we only monitor improvements in hygiene practices and behaviours and not outcomes of improved hygiene in a WASH project life cycle?

WHEN YOU CHANGE YOUR THINKING YOU CHANGE YOUR BELIEFS WHEN YOU CHANGE YOUR BELIEFS YOU CHANGE YOUR EXPECTATIONS WHEN YOU CHANGE YOUR EXPECTATIONS YOU CHANGE YOUR ATTITUDES WHEN YOU CHANGE YOUR ATTITUDES YOU CHANGE YOUR BEHAVIOURS WHEN YOU CHANGE YOUR BEHAVIOURS YOU CHANGE YOUR PERFORMANCE WHEN YOU CHANGE YOUR PERFORMANCE YOU CHANGE YOUR LIFE IMPORTANT TIPS FOR LIFE

BCC in WASH mostly copies commercial advertising techniques of selling behaviour change to consumers Re enforces gender, caste and class stereotypes Behaviour change in WASH is a politically sensitive issue; Needs to address individual and social self perceptions of caste and class – to give respect to what they do first before asking them to practice improved WASH behaviours Not simply a matter of giving knowledge and translating attitudes into improved behaviour/practice in WASH Can government/state agencies do this? Who will do BCC work – need extension workers. Can a “village community” of a mixed caste village enforce behaviour change? Can we expect an urban “slum community” to manage community toilets without trouble from anti social elements? BCC in WASH: Conclusions

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