Scaling up and sustaining behaviour change


With the sanitation crisis still widespread, water, sanitation and hygiene (WASH) practitioners are actively looking for ways to scale up and sustain sanitation and hygiene improvements. Some key questions are: What does ‘scaling up’ sanitation and hygiene behaviour change mean for WASH practitioners? How can sanitation and hygiene behaviour change be sustained? How should ‘slippage’ from open defecation free (ODF) status be defined and mitigated?

All of these questions were explored in the first ever online discussion bringing together the WSSCC Community of Practice on Sanitation and Hygiene in Developing Countries and the Sustainable Sanitation Alliance (SuSanA).

Held in late 2015 for three weeks, the overarching theme of the joint discussion was ‘Sanitation and hygiene behaviour change programming for scale and sustainability’. This theme was divided into three inter-linked sub-themes, namely ‘Programming for scale’, ‘Sustainability for behaviour change’ and ‘ODF slippage’. The global discussion was an unprecedented opportunity for the two networks, both of which have over 5,000 members, to share learning and explore links between research and practice on sanitation and hygiene behaviour change.

Scaling up behaviour change: a “wicked problem”

In the first week of the discussion, participants worked to define scale for sanitation and hygiene behaviour change programming, share examples of successful scale-up and understand stakeholders’ responsibilities and relationships. Suvojit Chattopadhyay, a consultant focused on monitoring and evaluation, described the sanitation challenge as a “wicked problem” and highlighted the complexity of inducing lasting behaviour change:

“The very nature of careful social engineering required to bring about this behaviour change seems to run contrary to some of the factors that make an intervention scalable – an ability to standardize inputs and break programme components down to easily replicable bits.”

Another challenge highlighted was that the different elements of WASH programmes do not scale up in the same way or through the same mechanisms. As Roland Werchota from the German international development organization GIZ noted, behaviour change at scale alone does not necessarily mean that scale is also reached on access to sanitation.

Anand Shekhar, programme manager for WSSCC’s Global Sanitation Fund (GSF)-supported programme in India, provided an example of successful scale-up in his country. The process of scaling up and achieving ODF status in Nadia District in West Bengal required stakeholders to uphold and share a set of key values including decentralization, joint planning, co-financing and collective action. In addition, several participants noted that there is a need to look beyond the WASH sector for successful scale-up examples – livelihoods programmes, for example, could provide good inspiration.

Participants agreed that there is a need to continue to learn how to effect systemic sanitation and hygiene behaviour change in different contexts. They also noted that the WASH sector should work more with non-traditional partners and experts, such as anthropologists, sociologists and psychologists, to better understand behaviour, and with the private sector, to learn more about innovative communication campaigns.

Sustaining behavior change: challenges and techniques

The second week explored the social and behavioural norms and dynamics that influence hygiene practices, specifically handwashing and the use of sanitation facilities.

Participants highlighted some of key ways to ingrain handwashing and latrine use within existing socio-cultural beliefs and norms, such as: using religious scripture related to hygiene; building on traditional beliefs about hygiene; experiential learning; linking hygiene to social status, dignity and pride; and influencing the young.

Participants agreed that understanding the incentives and internal motivations for behaviour change is key to designing related techniques. As such, and as highlighted in the previous week, behaviour change techniques must be tailored to the context. It was also stressed that creating an enabling environment for behaviour change is key, with techniques such as training health promoters to conduct awareness sessions, training latrine construction workers and plumbers, and building demonstration latrines in pilot areas.

Findings from a systematic review conducted by the International Initiative for Impact Evaluation (3ie) were also shared to highlight challenge of sustaining behaviour change:

“Barriers to behaviour change depend on the stage of the project. Many studies assess the health benefits of initial uptake of safe water, hygiene and sanitation technologies and practices. But few studies consider sustained use. The early project period may be characterized by enthusiasm over the new technology or promotional activities. Although external support ends during the early post-project period, the promotional messages may still be fresh in people’s minds. However, influential household members who were skeptical may reassert their domination during this phase. And finally, in the late post-project period stockouts, technology failure or poor maintenance systems can pose a serious threat to sustained adoption.”

The review also 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.”

In terms of behaviour change techniques, participants suggested that hygiene promotion should be integrated as much as possible within the existing health system rather than setting up parallel systems. Others suggested that volunteers, as opposed to paid professionals, should be used for health promotion, as studies have shown this to be more effective for behaviour change.

Other highlighted techniques included the RANAS model for systematically mapping potential behavioural determinants (based on human psychology) and then linking them practically to specific behaviour change technologies and integrating multi-faceted, holistic and context-specific monitoring and evaluation systems into behaviour change programmes.

How should we manage ‘slippage’?

In the third and final week, the conversation moved on to address what happens when there is a return to previous unhygienic behaviours or an inability of some or all community members to continue to meet all ODF criteria.

As colleagues from the GSF pointed out:

“...there is a lack of clarity (or at least acceptable/universal definitions) of what slippage actually is and there is no panacea for how to come to terms with slippage, which is dynamic and context specific. What we do know is that slippage is an expected aspect of sanitation interventions, especially those at scale, and NOT a sign of a failure thereof.”

Addressing patterns of slippage, GSF colleagues noted that “sanitation and hygiene behaviour change is a non-linear process” and “the more often interventions are repeated and follow-up support is provided, the less dramatic the slippage will be until eventually a level of maturity is met and behaviours ‘stick’.”

Key ODF slippage factors shared by colleagues included:

  • Socio-cultural aspects such as communal conflict
  • Environmental aspects such as flooding
  • Financial/economic aspects such as unaffordable hardware
  • Political aspects such as unhealthy competition between local governments
  • Programme limitations, such as weak CLTS triggering facilitation

Participants also agreed that the roles and responsibilities of key stakeholders in managing ODF status must be further clarified. Highlighting the role of WASH practioners, Joséa Ratsirarson from the GSF-supported programme in Madagascar said:

“Once identified, facilitators should help the community to find its own solution rather than bringing external solutions to them. We, as external to the community, cannot just solve nor have all the solutions. The problem comes from within the community and therefore the solution should be community-led, our role is to facilitate the process of finding these internal solutions.”

Strategies for preventing and mitigating slippage included:

  • Establishing WASH Clinics, which bring together a group of villages to review progress across all communities
  • Establishing Local Task Groups on Sanitation consisting of local government staff, religious leaders and traditional leaders. In Nigeria, their role is to conduct monthly verification of ODF communities, and they have also been used to advocate to 'stubborn' or lagging communities
  • Establishing WASH Committees within the communities themselves to support ODF achievement and sustainability
  • Incorporating CLTS triggering in larger initiatives that go beyond sanitation and hygiene
  • Supporting demand creation activities
  • Understanding why slippage has happened in order to inform effective and context-specific solutions
  • Establishing robust monitoring and evaluation systems

At the end of the discussion, participants agreed that there is a need to continue ‘learning by doing’, to improve knowledge and capacity in scaling up and sustaining sanitation and hygiene behaviour change.

Read more about the discussion by downloading the complete summary report.