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Journal of Health CommunicationInternational Perspectives

ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcm20

Use of Behavior Change Techniques in CleanCooking Interventions: A Review of the Evidenceand Scorecard of Effectiveness

Nicholas J. Goodwin, Sarah Ellen O'Farrell, Kirstie Jagoe, Jonathan Rouse,Elisa Roma, Adam Biran & Eric A. Finkelstein

To cite this article: Nicholas J. Goodwin, Sarah Ellen O'Farrell, Kirstie Jagoe, Jonathan Rouse,Elisa Roma, Adam Biran & Eric A. Finkelstein (2015) Use of Behavior Change Techniques inClean Cooking Interventions: A Review of the Evidence and Scorecard of Effectiveness, Journalof Health Communication, 20:sup1, 43-54, DOI: 10.1080/10810730.2014.1002958

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Use of Behavior Change Techniques in Clean CookingInterventions: A Review of the Evidence and Scorecardof Effectiveness

NICHOLAS J. GOODWIN1,2, SARAH ELLEN O’FARRELL1, KIRSTIE JAGOE3, JONATHAN ROUSE4,ELISA ROMA5, ADAM BIRAN5, and ERIC A. FINKELSTEIN6

1Tulodo, Sydney, New South Wales, Australia2Department of Media and Communications, University of Sydney, Sydney, New South Wales, Australia3Independent Consultant, Montreal, Quebec, Canada4HED Consulting, Bridport, Dorset, United Kingdom5Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine,London, United Kingdom6Duke University Global Health Institute, Durham, North Carolina, USA

Despite decades of effort, around 2.8 billion people still rely on solid fuels to meet domestic energy needs. There is robust evidencethis causes premature death and chronic disease, as well as wider economic, social, and environmental problems. Behavior changeinterventions are effective to reduce exposure to harm such as household air pollution, including those using health communica-tions approaches. This article reports the findings of a project that reviewed the effectiveness of behavior change approaches incleaner cooking interventions in resource-poor settings. The authors synthesized evidence of the use of behavior change techniques,along the cleaner cooking value chain, to bring positive health, economic, and environmental impacts. Forty-eight articles met theinclusion criteria, which documented 55 interventions carried out in 20 countries. The groupings of behavior change techniquesmost frequently used were shaping knowledge (n¼ 47), rewards and threats (n¼ 35), social support (n¼ 35), and comparisons(n¼ 16). A scorecard of behavior change effectiveness was developed to analyze a selection of case study interventions. Behaviorchange techniques have been used effectively as part of multilevel programs. Cooking demonstrations, the right product, andunderstanding of the barriers and benefits along the value chain have all played a role. Often absent are theories and modelsof behavior change adapted to the target audience and local context. Robust research methods are needed to track and evaluatebehavior change and impact, not just technology disseminated. Behavior change approaches could then play a more prominent roleas the ‘‘special sauce’’ in cleaner cooking interventions in resource poor settings.

This article reports the findings of a review into the effectivenessof behavior change approaches in cleaner cooking interventionsin resource-poor settings (Goodwin et al., 2014). The review pro-duced evidence on the use of behavior change techniques(BCTs), a behavior change framework for clean cooking anda set of seven case studies, using a scorecard of effectiveness.The recommendations do not include an attempt to highlightor rank the most effective behavior change models or theories;rather, the review captures the key elements that make behaviorchange approaches more likely to succeed in ensuring the scaleand sustainability of cleaner cooking interventions.

Despite decades of effort, around 2.8 billion people world-wide still rely on solid fuels such as wood, dung, and coal tomeet their basic domestic energy needs (Bonjour et al., 2013).Typically, solid fuels are burned on open fires or on inef-ficient stoves, which leads to high levels of household air pol-lution. This pollution comprises a mix of toxic gases andparticles known to cause (a) premature death and chronicdisease in children and adults and (b) wider economic, social,and environment issues on a large scale (Lim et al., 2013).What people do, that is, their behaviors—for example, whichstove and fuel they use; where they burn fires; how they useventilation; and where children and adults are located—determines the intensity of this impact (Smith et al., 2014).

Some of the most significant barriers to the adoption ofcleaner cooking practices are the entrenched complexbehaviors that characterize stove and fuel use across theworld. The field of behavior change provides frameworksand new ways of addressing these barriers (Jackson, 2005;

Address correspondence to Nicholas J. Goodwin, Tulodo, 6=57-59 Frederick Street, Ashfield, Sydney, NSW 2131, Australia.E-mail: nick@tulodo.com

Color versions of one or more of the figures in the articlecan be found online at www.tandfonline.com/uhcm.

Journal of Health Communication, 20:43–54, 2015

Copyright # Taylor & Francis Group, LLC

ISSN: 1081-0730 print/1087-0415 online

DOI: 10.1080/10810730.2014.1002958

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Maio et al., 2007). Historically, many behavior changeinterventions have been based on rational cognitive modelsof behavior. Scientists now understand the primacy of non-cognitive influences, such as emotion, on behavior (Biranet al., 2014; Kahneman, 2011; Loewenstein, Weber, Hsee,& Welch, 2001). There has also been a move towardmultilevel intervention models based on evidence from thefields of HIV=AIDS, sanitation, smoking, reproductivehealth and water (Glanz, Rimer, & Viswanath, 2008). Oneexample of a multilevel model is social marketing, whichincludes the concept of exchange (cost vs. benefit) thatunderpins the relationship between the consumer anda brand (French, 2006). An effective intervention strategyhas been the use of change agents (e.g., peer educators,community health workers) to help bring behavior changeinterventions to scale (Valente & Pumpuang, 2007).

There is a growing base of evidence that behavior changeinterventions are effective, including those using healthcommunications approaches. A 2014 review carried out byPopulation Services International found evidence that socialmarketing was an effective strategy for addressing HIV,reproductive health, malaria, child survival, and tuberculosisprograms in developing countries (Modi & Firestone, 2014).A 2010 meta-analysis of health campaigns, such as seat beltuse, oral health, alcohol use reduction, heart disease preven-tion, smoking, mammography and cervical cancer screening,and sexual behaviors, found small measurable effectson behavior change (Snyder et al., 2004). A 2014 review ofsanitation social marketing interventions by Evans andcolleagues found improvements in behavioral mediators,such as knowledge, attitudes and beliefs, with mixed resultsin behavior change (Evans et al., 2014). The role ofregulation in concert with behavior change and policy hasbeen shown to be effective (Hoek & Jones, 2011). Withinthe cleaner cooking sector, previous evidence includesa 2014 review of studies on child health which found thatbehavior change strategies can reduce household air pollutionexposure by 20–98% in laboratory settings and 31–94% inthe field (Barnes, 2014). There has also been recent work onthe determinants, or factors, that determine the barriers andbenefits to behavior change in the cleaner cooking sector(Lewis, 2012; Puzzolo, Pope, Bruce, & Rehfuess, 2013).

Method

This United Kingdom Department for InternationalDevelopment (DFID)—funded desk review was carriedout to analyze the use and effectiveness of behavior changeapproaches in cleaner cooking interventions withinresource-poor settings. It is recognized that to achieve truly‘‘clean cooking,’’ a switch to liquid fuels such as liquefiedpetroleum gas (LPG) or ethanol is required for all or mostof the cooking in a community. Many factors, includingeconomic and logistical barriers, means that this may notbe realistic for large numbers of households now or in theimmediate future. There are currently several types ofimproved solid fuel stoves, which range in their ability toreduce household emissions. The forced draft or semi-gasifier

stoves have shown the potential to achieve low emissionswhereas the more widely used ‘‘rocket’’ stoves produce moremodest changes. In practice, very few intervention stoves orfuels are able to provide the reductions in air pollutionnecessary to alleviate the health impacts associated withcontinual exposure to biomass smoke (World HealthOrganization, 2010). Discussions on what constitutes theterm clean in relation to stoves and fuels are ongoing andchallenging. For the purpose of this article, we used the termcleaner cooking interventions to include any intervention,stove, fuel, ventilation such as a chimney=smoke hood,and=or education program that aims to reduce levels ofhousehold air pollution and personal exposures.

The report was commissioned as part of DFID’s supportfor priority research to help deliver clean cooking solutionsat scale. The team comprised experts in behavior change,health, economics and clean cooking from a consortium ofspecialist agencies and universities. The team first carriedout a literature review to synthesize the evidence of the useof behavior change techniques (BCTs) for health, economicand environmental outcomes and impact. This was followedby a deeper analysis of effectiveness in terms of behaviorchange in relation to a selection of seven ‘case study’projects, chosen to provide an illustrative range of BCTs,geographical location, cleaner cooking technology and scale.1

Four intervention elements were selected for review—impacts, outcomes, intervention, and BCTs. We hadconsidered covering only those interventions that use andevaluate the impact of one of the more widely used behaviorchange models or theories. After discussion of an initialreview of the literature, we determined that this would poten-tially exclude useful interventions and so we decided to focuson the building blocks for these theories and models, namelyBCTs. The four elements do not always represent distinctand separate levels. A cleaner cooking intervention maycontain numerous BCTs and work toward achieving severaloutcomes and impacts. Other projects—often the smaller,randomized controlled trials—may only use one BCT, andin effect the intervention is the BCT and vice versa.

For the purpose of this review a BCT is defined as theactive component within a cleaner cooking intervention thatcatalyzes a behavior change. BCTs can be identified in activi-ties undertaken at several points along the cleaner cookingvalue chain, including design, production, finance, distri-bution and maintenance (Hart & Smith, 2013). A long listof BCTs was produced from published lists (Michie et al.,2013). These were then clustered into eight BCT groups toenable a manageable reporting mechanism (see Table 1 forfull list of BCTs used and their definitions). These groupingswere produced in advance of the search and then reviewed,validated and updated throughout the process.

The search terms reflected the fuels, stoves and householdmanagement practices at the center of cleaner cookinginterventions and were based on previous systematicreviews carried out in the cleaner cooking sector (Puzzolo

1The full list of 55 interventions is available separately or as part of the

full report at http://tulodo.com/2014/09/26/report-behaviour-change-clean-

cooking-interventions/.

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et al., 2013). The search included all fuel types includingclean fuels such as biogas, ethanol, and LPG. These termsincluded chullah, LPG, biogas, and cookstove and theirvariations. The BCT-related terms were informed by termsused in behavior change literature and ranged from the verybroad (e.g., intervention, behavior change) to the very specific(e.g., habit, trigger, and norm; Lee & Kotler, 2011; Michieet al., 2013; U.K. Cabinet Office, 2010). A search of thepublished, peer-reviewed literature was conducted usingmajor online research databases and the unpublished (gray)literature was also searched as systematically as possible.The search was augmented with personal communicationand hand searching of references. The full list of databasesand websites searched is shown in Table 2.

This search process produced a long list of uniquearticles=reports, which was then screened to ensure thoseincluded met the following criteria: (a) described cleanercooking interventions as defined by the team; (b) used oneor more BCTs from the list; (c) implemented in low,low-middle, and upper-middle income countries as definedby the World Bank income region classifications (WorldBank, 2014); (d) documented in English; (e) publishedand=or implemented since 2000. Documents describing for-mative research, or purely conceptual work, were excluded.

Multiple steps were taken to ensure the quality of theliterature identification and data extraction process.

Case Studies

Seven interventions identified through the literature review,were chosen as case studies to provide an illustrative rangeof BCTs, geographical location, cleaner cooking technology,funders and scale. The case studies were developed fromdata collected through the literature review and supplemen-ted when possible with personal communications with pro-ject staff. Because of heterogeneity of evidence types fromthe peer-reviewed and gray literature and the limitedresources of the team, assessment of the strength of evidencewas only applied to the main sources of evidence for theseven case studies.

To evaluate the case studies, a scorecard of behaviorchange effectiveness was developed, drawing on existingscorecards and frameworks (Dolan, 2010; French, 2006;Michie, van Stralen, & West, 2011). The scorecard2 outlinesbenchmark criteria for an effective behavior change

Table 1. Cleaner cooking behavior change technique groupings

Behavior changetechnique groupings Description

Example for cleanercooking sector

Reward and threat Makes the adoption of behaviors seem attractive or makes the failure toadopt practices seem threatening. It is linked to the concept of ‘‘valueexchange’’, i.e., what desirable outcome would the audience receive fortheir compliance, or what undesirable outcome would they avoid.

Incentives for households tobuy stoves

Shaping knowledge This helps people to understand what cleaner cooking behaviors are, howto perform them, and where to acquire the technologies and materialsneeded.

Radio announcements onstove availability

Changing thephysicalenvironment

Involves structural changes to the surrounding environment. It also refers toresetting environmental defaults so that a new behavior is easier to sustaindue to sympathetic cues and triggers.

Construction of a smokehood, chimneys and flues

Social support Involves providing resources and facilitating influence. ‘‘Seeding’’ a newbehavior with an trusted person or group helps ensure the new behaviorappears desirable and starts to become the norm, leading people towant to emulate and model it.

Community health workersadvising on fuel choice

Goals, planning andmonitoring

Working with an audience’s goals involves unearthing their aspirations,ambitions and intentions, reframing the new behavior as a way ofachieving these goals, and then facilitating the audience in realizing theirgoals through the medium of the new behavior.

Purchasing plans for newstoves

Comparisons Provides a choice of options and the opportunity for people to comparewhat is available with those chosen by their peers, neighbors, friendsand families.

Making a variety of stovemodels available

Identity andself-belief

Targets audiences according to their actual or aspirational roles. Gender andother roles determine how we perceive ourselves, how we are perceived,and how we are expected to think and act.Linked to this isthe process of increasing people’s sense of self-efficacy and buildingmomentum behind a desire to change their behavior

Empowering women to decideon stove choice

Regulation Regulatory mechanisms include bans and restrictions, or industry standards.They are a measure of enforcement as opposed to persuasion, and canamplify ‘‘softer’’ behavior change techniques.

Restrictions on the use ofcertain fuel types

2The scorecard is available at http://tulodo.com/2014/09/26/report-

behaviour-change-clean-cooking-interventions/.

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intervention. The criteria were as follows: (a) behavior focus,(b) target population, (c) barriers and benefits, (d) methods,(e) capacity building, (f) behavior change results, (g) out-comes, and (h) impact. Each case study includes scores basedon these eight criteria, each containing two to three ques-tions. Each question was worth 1 point for a maximum poss-ible total of 22 points for each intervention, which was thenconverted to a percentage score for overall behavior changeeffectiveness. We started the process of testing and validat-ing the scorecard by assessing the case studies, and it evolvedduring this process.

The information used to generate the scores is basedsolely on the desk review, supplemented when possible withpersonal communication with representatives from theimplementing organization. No further field research orindependent verification was conducted. The score doesnot imply a rating for the intervention’s overall effectiveness,as there are other variables and data not captured or verifiedby this study. This includes the technical aspects of the tech-nology (especially stoves and fuels) used as well as the scale

and sustainability of impact. The scores are summarized inTable 4. For each of the case studies, the team also assessedthe strength of evidence for one to two of the primary evi-dence sources using a previously validated tool (DFID,2014).

Results

The search process yielded a list of 207 unique references.After removing those not meeting the inclusion criteria, 48articles documenting 55 cleaner cooking interventionsremained (see Figure 1). These related to all aspects of thecleaner cooking value chain—32 in Asia, 15 in Africa, and8 in the Americas—covering a total of 20 countries. The finallist of articles was then reviewed, each one was tagged and itsinformation extracted.

Results: BCT Level

Table 3 provides a summary of the BCTs identified in thesearch. The most frequently used BCT is that of shapingknowledge, found in 47 cleaner cooking interventions(85%). An example of this was used by the Improved Cook-stove Program led by the Bangladesh Council of Scientificand Industrial Research, which included local demonstra-tions and seminars, attended by representatives of localgovernment. This was supplemented by subsidized advertise-ments and short films, which created a high level of demandfor cookstoves (World Bank, 2010).

The next most frequently found BCT group is rewardsand threats, with 35 interventions (64%) applying thistechnique. For example, in Indonesia, the Domestic BiogasProgram (known locally as Biogas Rumah or BIRU), ledby the Dutch nongovernmental organizations SNV andHIVOS, offered end users of biogas digesters an investmentincentive of approximately 25% (Toba, 2013). Social supportwas a BCT used in 35 interventions (64%). The Indoor AirPollution Reduction Program, led by Concern, VERC, andWinrock International in northern Bangladesh, established

Table 3. Impacts and behavior change techniques identified inliterature search (N¼ 55)

Category Interventions n (%)

Behavior change techniquesShaping knowledge 47 (86)Reward and threat 35 (64)Social support 35 (64)Comparisons 16 (29)Identity and self-belief 15 (28)Regulation 15 (28)Changing the physical environment 10 (18)Goals, planning and monitoring 3 (6)

ImpactEconomic 37 (67)Health 32 (58)Environmental 20 (36)

Table 2. Literature sources

Academic databases Gray literature

. EPPI-Centre database of health promotion research (Bibliomap)

. Campbell Library

. Cochrane Library

. MEDLINE (Ovid)

. Database of Promoting Health Effectiveness Reviews (DoPHER)

. Public Library of Science (PLoS)

. PubMed (NIH)

. EconLit (EBSCO)

. International Encyclopedia of the Social andBehavioral Sciences

. Web of Knowledge

. International Initiative for Impact Evaluation (3ie)

. Research for Development (DFID)

. Ashden Awards for Sustainable Energy

. EnDev

. Global Alliance on Cleaner Cookstoves (GACC)

. Global Village Energy Partnership (GVEP)

. HEDON

. Partnership for Cleaner Indoor Air

. WHO effectiveness review database

. Renewable Energy and Energy Efficiency Partnership

. USAID

. WASHPlus IAP Updates

. World Bank Energy Sector Management AssistanceProgram (ESMAP)

. Google Scholar

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Table 4. Case study interventions

InterventionLead

organizationBehavior changetechniques used

Score of behaviorchange

effectivenessScorecard of behaviorchange effectivenessa

Strength of evidenceassessment

CambodiaFuelwoodSavingProgram

Geres Reward andthreat

Shapingknowledge

Social supportComparisonsRegulation

77% 1. Behavior focus 1=32. Target population 3=33. Barriers and benefits 3=34. Methods 2=25. Capacity Building 2=36. Behavior change 1=37. Outcomes 3=38. Impact 2=2

Geres (2010): Low

China NationalImprovedStove Program

Ministry ofAgriculture

Reward andthreat

Shapingknowledge

Social supportGoals, planning

and monitoringRegulation

64% 1. Behavior focus 2=32. Target population 2=33. Barriers and benefits 2=34. Methods 2=25. Capacity Building 2=36. Behavior change 0=37. Outcomes 3=38. Impact 1=2

Sinton et al. (2004):High

Edwards et al.(2007): High

EnergisingDevelopmentKenya CountryProgramme

GIZ Shapingknowledge

Change thephysicalenvironment

Social supportComparisonsGoals, planning

and monitoringRegulation

86% 1. Behavior focus 3=32. Target population 3=33. Barriers and benefits 3=34. Methods 2=25. Capacity Building 3=36. Behavior change 0=37. Outcomes 3=38. Impact 2=2

Reports receivedfrom EnDev didnot sufficientlyoutline theevaluationscarried out to gainthe impact data toallow anassessment of thestrength ofevidence to beconducted.

India Room toBreathe

ShellFoundation

Shapingknowledge

Social supportComparisonsGoals planning

and monitoring

73% 1. Behavior focus 3=32. Target population 3=33. Barriers and benefits 3=34. Methods 2=25. Capacity Building 3=36. Behavior change 0=37. Outcomes 2=38. Impact 0=2

Shell Foundation(2013): Moderate

Berkeley AirMonitoringGroup (2011):Moderate

Indonesiankerosene toLPGconversionprogram

Pertamina Reward andthreat

Shapingknowledge

Change thephysicalenvironment

Social supportComparisonsRegulation

86% 1. Behavior focus 2=32. Target population 3=33. Barriers and benefits 3=34. Methods 2=25. Capacity Building 3=36. Behavior change 2=37. Outcomes 2=38. Impact 2=2

Budya & Arofat(2011): Low

Wibowo (2013):Low

South AfricaNorthwestProvinceBehaviorChange Study

University ofWitwaters-rand

Reward andthreat

Shapingknowledge

Social supportGoals, planning

and monitoring

80% 1. Behavior focus 3=32. Target population 3=33. Barriers and benefits 2=34. Methods 1=25. Capacity Building 3=36. Behavior change 2.67=37. Outcomes 3=38. Impact 0=2

Barnes et al. (2011):High

Barnes et al. (2004):High

(Continued )

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a cadre of promoters and community leaders. This alsoensured local capacity to carry on all aspects of the inter-vention beyond the life of the project (Winrock, 2009).

Comparisons-based approaches were used in 16 interven-tions (29%) to encourage new behaviors. The TezulutlanImproved Stove Project in the Baja Verapaz region ofGuatemala contacted local leaders interested in promotingthe intervention stoves. The team visited the homes of theselocal leaders, built the Tezulutlan stove and monitored itsperformance. Subsequently, the local leaders were asked to

invite friends and family to view the stove and evaluate itsperformance in comparison to those previously used(Ahmed et al., 2005). Also, 15 interventions (27%) usedidentity=self-belief BCTs, for example the Deepam Schemeto promote LPG connections in the Indian state of AndhraPradesh was implemented through established grassrootswomen’s self-help groups. This served to link the promotionof LPG to support for women’s development and financialindependence (Rajakutty & Kojima, 2002).

Fifteen interventions (27%) also contained regulation as aBCT. In Lao PDR, the government identified the develop-ment of regulations and guidelines as key to success forthe Cleaner Stove Initiative (Toba, Tuntivate, & Tang,2013). Also, 10 interventions (18%) involved changes in thephysical environment as a BCT. India’s Hindustan PetroleumCorporation Rasoi Ghar program facilitated cleaner andsafe cooking by adapting the traditional concept of the com-munity kitchen, or Sanjha Chulha (World LPG Association,2005). Activating people’s goals was the least widely foundBCT, only documented in three interventions (5%). Oneexample stems from PATH’s research in Uganda to identifyits audience’s motivations for adopting the new stove.PATH found that fathers were motivated to be seen as moresophisticated and better-off than their neighbors (Mugisha,2014).

Results: Impact and Outcome Levels

Table 3 also provides a summary of the impacts and out-comes coded in the search – the health, economic andenvironmental benefits. Economic benefits (i.e., those docu-menting an economic related impact [negative or positive]),were widely reported (n¼ 15 articles and n¼ 37 interven-tions). For example, in the Bangladesh Council of Scientificand Industrial Research Improved Cookstove Program,84.5% of user households reported financial benefits due todecreased expenditure on fuel (World Bank, 2010).

The next most frequent documented impact was health(and safety related) benefits (n¼ 24 articles and n¼ 32 inter-ventions). For example, the Ugandan Energy Saving Stove

Table 4. Continued

InterventionLead

organizationBehavior changetechniques used

Score of behaviorchange

effectivenessScorecard of behaviorchange effectivenessa

Strength of evidenceassessment

Strategies forImprovedCookstoveAdoption inRural Uganda

ImpactCarbon

Goals planningand monitoring

Shapingknowledge

Social supportComparisons

82% 1. Behavior focus 3=32. Target population 3=33. Barriers and benefits 3=34. Methods 2=25. Capacity Building 2=36. Behavior change 3=37. Outcomes 2=38. Impact 0=2

Levine et al. (2014):High

Note. The case studies are available at http://tulodo.com/2014/09/26/report-behaviour-change-clean-cooking-interventions/.aEach question was worth one point for a maximum possible total of 22 points for each intervention, which was then converted to a percentage score foroverall behavior change effectiveness.

Fig. 1. PRISMA diagram of search process.

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Project reported a 21% reduction in acute respiratorydiseases among stove users. There was limited evidence ofdocumented environmental benefits (n¼ 12 articles andn¼ 20 interventions). However, those that were identifiedshowed significant impacts. Household surveys in Mexicoshowed a decrease in average wood fuel consumption of67% after the introduction of the Patsari stove (roughly3.5 tons of wood annually) (Troncoso et al., 2007).

Some of the studies identified did not report impacts. Inthese cases, intermediary outcomes, which could potentiallylead to the impacts, were included. The most frequentlyreported outcome was that of technology (stove and=orfuel) uptake (n¼ 25 articles and n¼ 47 interventions).The Mongolia Improved Space Heating Stoves Programexceeded its goal of disseminating 7,000 improvedcookstoves and distributed more than 15,000 units (WorldBank, 2010). Indoor air quality improvement was the nextmost documented outcome (n¼ 18 articles and n¼ 26interventions). An example of this is the Nepal HealthyHoods program implemented by Practical Action, whichsaw post intervention indoor particulate levels fall by 88%,from 13.2 to 1.6 parts per million (Malla et al., 2011).

Case Studies

Table 4 provides a list of seven interventions (projects, pro-grams, or studies) selected for development as case studies.3

These were chosen from the final 55 interventions to reflecta number of important and interrelated factors: geography,scale, implementer, funder, scope, impact, and BCT. Someare national-level programs (e.g., China, Indonesia), othersare smaller donor programs (e.g., Kenya, India), and yetothers are field experiments (e.g., South Africa, Uganda).The Americas are not represented, as sufficient data wasnot available for the project selected for inclusion. Thechoices do not reflect any endorsement of the projects, tech-nologies, or organizations involved. Information was takenfrom publicly available literature identified during the searchplus, where possible, personal communication with projectstaff. Not all project organizations could be contacted, andtherefore some gaps remain in the data reported.

Both GIZ’s EnDev program in Kenya and PertaminaIndonesia’s LPG conversion program received the highestscores of 86%. Impact Carbon’s Uganda project received82%, the University of Witwatersrand’s behaviour changestudy obtained 80%; Geres Cambodia received 77%; ShellFoundation Room to Breathe in India obtained 73%;and China’s NISP received 64%. The behavior changeeffectiveness scores cover a relatively narrow range—from64% to 86%. This reflects the fact that organizations withBCT components were specifically chosen so their imple-mentation within the cooking sector could be explored anddescribed. A more random sample from the full literaturereview results would have provided a much more diversebut perhaps less illustrative results. The scoring allowsfor comparison across the studies, focusing on a range of

elements identified by the authors as key to behavior changeinterventions.

Although the presence of BCTs was common, theirimplementation as part an established behavior changemodel or framework appeared to be rare. The ShellFoundation Room to Breathe project was one of onlya few interventions reviewed that used a leading behaviorchange model. The social marketing approach of the ShellFoundation program included flexible financing and a mixof promotion materials, group activities, and personalcommunications. The intervention also used early adoptersto demonstrate the technology, which is regarded as aneffective tactic for changing behavior (Valente & Pumpuang,2007). The inclusion of financial incentives and the engage-ment of change agents through partnerships with microfi-nance organizations boosted sales considerably. Althoughthe project did not meet the target of 50,000 units sold,with only 11,000 units purchased, the lessons learned haveenabled the Shell Foundation to improve the design of theirprojects in other countries (Shell Foundation, 2013).

Impact Carbon’s ‘Strategies for Improved CookstoveAdoption in Rural Uganda’ project included a 6-monthfeasibility study before commencement of a series ofrandomized controlled trials. The team considered this use-ful for the baseline data collection and formative research,as well as to test the key elements of the intervention,such as the available stoves and the marketing messagesfor local acceptance. The final selection of health, financialand time related messages are strong rational messages,but are often considered to be the minimum informationrequired to provoke behavior change within the targetpopulation and are usually not sufficient on their own tochange behaviors. The weak results showed that the marketingmessages had little impact on stove uptake but they do notexplain whether it was due to the communication channelsor the messages. Similarly, the success of the financial offerswas encouraging but it may have been the promotion duringgroup sessions that made them work effectively. It appearslikely that effective interventions require the benefits offlexible financing mechanisms communicated with therelevant emotional messages through the appropriate channels(Beltramo, Levine, & Blalock, 2014).

The University of Witwatersrand Northwest ProvinceBehavior Change Trial in South Africa did not include theuse, promotion, or sale of any technology. It tested onlymessages (on ventilation, location of cooking and people)to change people’s habits, delivered by health workers. Thework aimed to produce a ‘proof of concept’ to understandwhether behavior change has the potential to work in con-texts of extreme poverty, where solid fuels are burned oninefficient traditional stoves in poorly ventilated kitchens,and where access to cleaner technologies is limited botheconomically and geographically. To underpin the study’sdesign, it used the Trial of Improved Practices method,which is a formative research technique to pretest the actualpractices that a program will promote. This is similar toBandura’s technique of mastery modeling which breakssignificant behavior changes into smaller tasks. The combi-nation of measuring behavior change (observed and

3The full case studies are at http://tulodo.com/2014/09/26/report-

behaviour-change-clean-cooking-interventions/.

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reported) plus the household air pollution outcome wasconsidered useful. The significant reduction in householdair pollution achieved is encouraging but further study withlarger sample sizes is required to gain more conclusive results(Barnes, Mathee, & Thomas, 2011).

The Geres Cambodia Fuelwood Saving Program wasscored as highly effective, in part because it exceeded its salestargets. This project adopted a supply-side approach as itfocused on building the stove production and distributionnetwork. This project had other market-based solutions,which included incentives such as low-interest loans andbusiness advice. The focus on strengthening the capacity ofthe supply chain makes the change more likely to be sustain-able (Bryan et al., 2009). The project promoted a charcoalstove similar to stoves previously used in the target popu-lation. This minimized the degree of adaptation in cookinghabits demanded from the user and thus increased thelikelihood and ease of adoption. The likely effect ofthis type of stove has been the subject of much debate(Smith, 2014), with some saying that it would not producea significantly improved human and environmentalimpact (Smith et al., 2014).

Discussion

Analysis of the findings reveal a mixed picture of the use ofBCTs in cleaner cooking interventions. The BCTs and theactivities in which these have been used were identified,but less clear is their effectiveness to bring about desiredoutcomes and impacts. While some good quality data areavailable, often absent are data on the outcomes andimpacts of activities using BCTs, particularly those thatare directly attributable to the BC component. The lackof evidence for BCT impact means that the authors couldonly make best guesses on most ‘‘active ingredient’’ in theintervention. It also meant that it was not possible to carryout a robust meta-analysis of the impact or the originallyplanned cost effectiveness analysis. However, it was possibleto describe how the different types of BCTs were used andaugment that with an analysis using the benchmark criteriadeveloped for the Scorecard of Behavior Change Effectiveness.

There appears to be limited variation in the typesof BCTs used in the 55 interventions reviewed. Shapingknowledge, reward=threat, social support, and comparisonappear more often and usually in combination. This suggeststhat a typical cleaner cooking intervention is one thatpromotes an economic incentive for the new technologycombined with some form of social support. For example,the Shell Foundation developed partnerships with microfinance institutions in India, which it credited with a largepart of the success of the India Room to Breathe program(Shell Foundation, 2013). Impact Carbon used rent-to-ownmodels in Uganda to entice potential customers. BothEnDev and Geres used micro-credit schemes in Kenya andCambodia, respectively.

This suggests that the program designers consider theseBCTs most effective; however, the evidence for the choiceis not always clear. The most common forms of rewards

are economic ones, including the subsidies provided bygovernments, nongovernmental organizations, and otherproviders of cleaner cooking technologies. Subsidies, andother forms of discounting, can work for and againstadoption and sustained use, depending on how these aremanaged. Subsidies can provide access to better-performingstoves, which are often more expensive, but must be mana-ged to avoid negative effects on markets and the perceivedvalue of the products (Puzzolo et al., 2013). Little evidencewas found in the 55 cleaner cooking interventions thataccount for the influence of emotion and other subjective=affective experiences on decision-making and intent.

‘‘How’’ to deliver these BCTs was reported less consist-ently, including the channels through which the BCT iscommunicated, also known as the marketing mix. Forexample, posters were produced sometimes without testingor understanding how these would be received. This meantthat it is difficult to determine whether it was the BCT orits communication that was effective or, in fact, ineffective.There were notable exceptions, with several programs testingand revising their messages and materials based on feedback.This includes Impact Carbon in Uganda, EnDev in Kenyaand Shell Foundation in India.

A Behavior Change Framework for Cleaner Cooking

How to interpret a BCT and its relationship to otherelements in the cleaner cooking intervention frameworkwas not immediately obvious at the start of the project.An example is passing a law providing for a subsidy ora restriction on a particular fuel, such as on LPG in thePertamina Indonesia conversion program (Budya, 2011).To be effective, the law must be communicated (shapingknowledge), enforced (reward and threat) and sustained(social support). Which ones of these BCTs was effective?Using the evidence gathered through the case studies, theteam concluded that a mix of BCTs in an interventionshould target all aspects of the cleaner cooking value chain,e.g., GERES Cambodia focusing on the suppliers andShell Foundation in India focusing on user engagement.In addition, the framework should reflect the multilevel natureof development, which includes individual behavior, groupdynamics, environmental factors and social determinants.

The review carried out by Puzzolo and colleagues (2013)and similar research suggests that there are multiple deter-minants specific to each context. The determinants are theenabling or limiting factors, which can help ensure moresuccessful delivery of programs. The logical place for thedeterminants in the cleaner cooking behavior changeframework is between the intervention and outcomes.Using this finding, the team was able to position deter-minants in the behavior change framework for cleanercooking (see Figure 2).

Use of Theories of Change and Behavioral Approaches

The limited use of researched and tested theories of changeto underpin the design and implementation of interventionsis considered a shortcoming for many of the programs

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reviewed. A program theory of change enables the interventionmanager to set out and articulate the concepts and assump-tions that underpin the anticipated change process.Most interventions are framed around a belief about howthe program will work, but the process through which theoutputs will turn into outcomes needs to be consideredand articulated, and its theoretical foundations made explicit(Vogel, 2012).

Compared with other sectors, there is a relative absenceof specific strategies, plans and activities based on behaviortheory, models and research. For example, shaping knowledgewas the most frequently used BCT found in this study;however, there was often little demonstrated understandingof how people produce, use, and share information. Becauseinterventions did not explicitly use or refer to behavioral mod-els or theories, it is more difficult to determine why these wereor were not effective. This makes expansion and learningfrom others more problematic.

There are some notable exceptions. As previously dis-cussed, some of the case studies did use behavior changemodels, such as the Shell Foundation Room to Breatheproject’s use of social marketing. The Shell Foundationpaid close attention to the barriers to change and developedthe marketing campaign to promote the benefits of the newtechnology for the family. It also focused on the decisionmaking process for stove acquisition, including the dynamicsbetween the husband and wife (Shell Foundation, 2013).Mexico’s Patsari program adopted an approach basedon Diffusion of Innovation theory, in this case focusingon the dynamics around the intensity of stove use as theinnovation to be diffused (Pine et al., 2011).

Limitations

The review did not yield the type and extent of informationto allow conclusions to be drawn on the most effective BCTnecessary for the success of cleaner cooking interventions.However, analysis of common themes from the literaturereview and case studies in addition to drawing from othersectors identified some strong trends and probablerelationships, which can guide practice and further research.

The lack of consistent and credible evidence for cleanercooking interventions using BCTs restricted our ability todraw conclusions across the sector. We had planned toconduct a cost-effectiveness analysis to provide a compari-son between the case studies; however, the available datadid not allow for this to occur. In some cases, impact andoutcome measures were not collected; in others, the costinformation was not available. Also, the measures ofeffectiveness differed across interventions (e.g., for healthand economic impacts), which means direct comparisonwas not possible.

Recommendations and Conclusions

Intervention designers should develop a program-specifictheory of change to show how the expected outcomes willbe achieved in a population given the local conditions.This may include replicating a similar intervention (orcombination of activities) in comparable circumstances.Making the intervention’s hypothesis explicit and discussingthe strength of evidence that supports it will provide a moresolid foundation for the planned path from outputs tooutcomes. Managers and researchers in the clean cookingsector are strongly encouraged to consider incorporatingstrategies, plans and activities based on behavioral theory,models, experience and research. As part of this, they shouldreport the use of behavior change theories, models andtechniques. To assist in this process, a useful tool would bea guide on implementing behavior change in clean cookinginterventions.

We identified a journey to scale in which programsreached a tipping point after which the new cleaner cookingtechnology became the norm. An example is Indonesia’stransition to LPG, which experienced significant problemsand resistance in the early stages. It was able to learnfrom these problems and adapt the rollout of the program,including reaching out to change agents in beneficiarycommunities as part of its socialization activities. This,combined with a strong national regulatory framework,appeared to ensure the conversion program reached thetipping point and national adoption.

The review also highlighted that several successfulinterventions took into account the various relationshipsand dynamics, including those at the individual, inter-personal, community and national levels. It appears thatit is not enough to address personal perceptions andbehaviors; interventions must include activities that reflectthe relationships in the household as well as social normsand national regulations. For example, Shell Foundation’sRoom to Breathe project in India shows that social marketing

Fig. 2. Cleaner cooking intervention framework.

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messages must be convincing for the women who are doingthe cooking, as well as to both husband and wife who sharethe decision making and interact with their communities(Shell Foundation, 2013). In contrast, the more top-downinterventions, such as India’s National Biomass CookstovesInitiative, did not appear to be based on research or activitiesdesigned to deal with behavioral challenges, nor engage localcommunities in the decision making or solutions for their ownproblems (Lewis & Pattanayak, 2012).

Another aspect of achieving scale is the recruitment ofchange agents and use of cooking demonstrations, whichconsistently appeared in many of the studies. The way theproducts are communicated to the community is important,including consultations with leaders, demonstrations andengagement of sales agents, health workers, and otherchange agents. Several projects recruited members of thetarget populations who were early adopters of cleanercooking technologies and then deployed them as changeagents in their communities. PATH’s project in periurbanUganda, found that peer led promotion, which involvedinviting current users of the intervention stove to speakabout their perceptions and experiences with the productat the demonstrations, was an effective strategy to increasestove uptake (Shell Foundation, 2013).

Drawing on the team’s finding that the identity andself-belief BCT was underrepresented, the role of gender isan important practical and moral consideration. This reviewfound evidence that programs with holistic gender sensitivedesigns were more effective. One example is the DeepamScheme to promote LPG connections in the Indian state ofAndhra Pradesh being implemented through women’sself-help groups. There is a growing recognition of theadvantages associated with actively involving women atevery stage of the cleaner cooking value chain (Hart,2013). However, gender empowerment approaches mostlyfocus on women and have positioned men as either absentactors or perpetrators of harmful practices. Interventiondesigns should consider how to work better with men ontheir terms to fulfill their needs and expectations. Thesetwo approaches will ensure a holistic gender strategy thatprovides benefits for all (Goodwin, 2013).

The use of brands has significant promise for this sectorbecause brands enable the grouping of behaviors underone strategic relationship umbrella (Evans et al., 2008).A stove has to be at least as good functionally (its intrinsicattributes) as the old one, otherwise all other efforts aremore likely to fail—and simultaneous use of multiple stoves(stove stacking) will continue. Also the aspirational andemotional appeal (the extrinsic attributes) of the brand mustbe strong. While this review did not cover the use of brandsspecifically, few of the programs reported investment inunderstanding and improving the relationship between theconsumer and their brands. One example of the use ofa well-recognized, respected brand to sell cleaner cookingtechnology comes from Unilever (2012). The company isusing their popular food flavoring, Royco, to sell a newcharcoal stove in Africa using the same name for theircleaner cook stoves. The use of the Royco brand would likely

draw on the trust Unilever has built in its brands in Africanhouseholds.

While the technology (especially stoves and fuels) was notan explicit focus for this study, it is worth emphasizing thatthe product must be appropriate on several levels for theintended users. Although there are many criteria that couldbe used to assess products, one useful set is the four productquality signals that have received significant attention in themarketing and economics literature: branding, pricing, physicalfeatures, and retailer reputation (Dawar & Parker, 1994).

Connected to this concept of getting the technology rightis the need to ensure the availability of accessible andappealing financing options. New stoves are often a largeinvestment for the targeted households and therefore cre-ative and realistic ways should be developed to enable andfacilitate the purchase. Financing options include subsidies,micro loans, trials and rent-to-own programs. An examplecomes from the Shell Foundation Room to Breathe project,which initially fell short of the sales momentum neededto achieve scale and impact. The project subsequently nego-tiated partnerships with microfinance institutions in Indiaand sales increased significantly (Shell Foundation, 2013).

The available evidence enabled a description and analysisof the behavior change approaches that are more likely to besuccessful in cleaner cooking interventions. Effective useof various BCTs as part of multilevel programs, the rightproduct, and understanding of the barriers and benefits tochange along the value chain have been shown to play a rolein effective interventions that address health, economic andenvironmental impact. However, clearly absent from manyprogram designs are the use of theories and models ofbehavior change, adapted to the target audience and localcontext. Underpinning this design should be strong researchmethods to track and evaluate the effect, not just in terms oftechnology disseminated but also in behavior change andimpact achieved. The sector would benefit from a practicalguide to effectively using behavior change approaches forcurrent and new programs. As the evidence base is builtfurther and different methods tested, we expect behaviorchange approaches to play a more prominent role as the‘‘special sauce’’ in cleaner cooking interventions in resourcepoor settings.

Acknowledgments

The authors thank the people who assisted them with thestudy. This includes Teljya Oka-Pregel for her contributionto development of the case studies; Eoin Martin for his assist-ance with tagging and data extraction; and David Lloyd forthe design of the final report. The authors also wish to thankthe external Quality Review Group (QRG) for their guidanceand support. The QRG were independent and volunteerexperts in behavior change, clean cooking and research:

. Brendon Barnes, Professor, University of Johannesburg,South Africa

. Nigel Bruce, WHO Consultant & Reader in Public Health,University of Liverpool, United Kingdom

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. Michael Dibley, Associate Professor of Public Health,University of Sydney, Australia

. W. Douglas Evans, Professor of Public Health and GlobalHealth, George Washington University, USA

. Kim Longfield, Director of Research & Metrics, Popu-lation Services International, USA

. Sumi Mehta, Director of Programs, Global Alliance forClean Cookstoves, USA

. Debbi Stanistreet, Senior Lecturer, Institute of Psychology,Health and Society, University of Liverpool, UnitedKingdom

This article is based on a report commissioned by theU.K. Department for International Development (DFID),authored by a team of independent consultants. The viewsexpressed in this report are those of the authors and donot necessarily represent the views of DFID or the QRGmembers. The case studies selected for this article do notreflect any endorsement of the projects, technologies ororganizations involved.

Authors’ contributions: NJG, SEO, KJ and JR conceivedthe study, designed the methods, supervised the literaturereview, supervised the analyses and drafted the write-up.NJG, SEO, KJ and JR undertook the literature review andperformed the coding. ER, EAF and AB drafted sectionsand commented on the write-up. All authors read andapproved the final manuscript.

Funding

This study was funded by the UK Department forInternational Development (DFID).

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