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National Conference for Household Water Treatment and Safe StorageJakarta, Indonesia. August 20-21, 2008
Maria Elena Figueroa
Understanding Behavior
Change for Safe Water
Photo by Risang Rimbatmaja
• Poor water quality continues to be a major health threat.
• Diarrhea alone kills worldwide, about 5 000 people, every day, most of them young children.
• Most of this problem, the result of unsafe water, poor sanitation and hygiene.
Why should we care about behavior for safe water?
Improved water sources and safe water
• 1.1 billion people lack access to improved water sources
• Recontamination due to transportation and storage
• Treatment at the household level, about 2x as effective as treatment at the sourceWHO, 2007; Clasen, 2005
Improved water sources and safe water
• 1.1 billion people lack access to improved water sources
• Recontamination due totransportation and storage
• Treatment at the household level, about 2x as effective as treatment at the sourceWHO, 2007; Clasen, 2005
Improved water sources and safe water
• 1.1 billion people lack access to improved water sources
• Recontamination due totransportation and storage
• Treatment at the household level, about 2x as effective as treatment at the sourceWHO, 2007; Clasen, 2005
Behaviors to address
POU water treatment technologies
• Boiling • Filters • Chlorination• Chlorination and
flocculation• Solar disinfection,• Others (UV light)
Water treatment and safe storage are not sustained
practices among people that need them most
Why is behavior so difficult to change?Why is behavior so difficult to change?
• Our assumptions are wrong• Many behaviors have powerful advocates • Some can, others can’t
Our behavior change interventions are based on our theories of behavior
change
What have been our assumptions What have been our assumptions and theories?and theories?
• Emphasis on health benefits, - disease, severity action-behavior
• Emphasis on attributes of the technology orthe service rather than consumer needs
- Knowledge – approval practice-use
These approaches have had limited effect
Most public health interventions worldwide:
COMMUNICATION
PSYCHO-SOCIAL FACTORS
COGNITIVEBeliefsValuesPerceived RiskSubjective NormsSelf-Image
EMOTIONALEmotional ResponseEmpathySelf-Efficacy
SOCIALBounded Norm. InfluencePersonal Advocacy
ENVIRONMENTAccess to Water Sources, Water and Sanitation Technologies &Community Organizations
SKILLS & KNOWLEDGEINSTRUCTION
NONDIRECTIVEDialogueCounselingEntertainmentSocial Networks
PUBLICServices Advocacy
reinforcement
enabling
Attitudes INTENTION
BEHAVIORWater Treatment and Safe Storage
Household Sanitation
Hand Washing
Community Sanitation
DIRECTIVEDisseminationPromotionPrescription
confirmation
Model of Communication and Behavior
Two key implications from this model
Two key implications from this model
1st: Behavior change programs need to address psychosocial factors if they
want to succeed
A predictive model of communication & change:Influence of ideational elements on behavior
Knowledge
Attitudes
Self-Image
Perceived Risk
Self-Efficacy Norms
Emotions
Social Support & Influence
Personal Advocacy
BEHAVIOR
Implies simultaneous effect of all influences.
Implies communication can affect all influences.
Examples from Guatemala and Examples from Guatemala and PakistanPakistan
Water treatment behavior, Water treatment behavior, GuatemalaGuatemala 20032003
Sample size = 1,500* Includes filter w/cloth/strainer, solar disinfection and others.
Treatment Method
35.5
2.5 1.2 0.3 0.5
60.1
0
20
40
60
80
100
Nottreating
Boiling Chlorine Filter PUR Other*
Percentage
Psychosocial factors identified for Psychosocial factors identified for water treatment in water treatment in GuatemalaGuatemala, 2003, 2003
1. Have positive attitudes toward water treatment
2. Like the taste of treated (boiled) water 3. Have self-confidence in the water they
prepare4. Have talked to their partner about treating
water5. Perceive the majority treats their water
Factors are context-specific
Percent of water treatment by the number of Percent of water treatment by the number of ideational factors which applyideational factors which apply
Guatemala Guatemala 20032003
Cumulative Number of Factors that ApplyChi2 (5 df) = 176.8 p<.001; N = 1,500
17
3441
6369
40
70
20
40
60
80
100
None 1 2 3 4 5 Overall
Percent
77
613
1 3 10
20
40
60
80
100
None Boiling ClothFilter
PuR Alum Others
Method Used
Percent
N = 1500
Water treatment behavior, Water treatment behavior, PakistanPakistan 20052005
1. Attitudes toward water treatment2. Knowledge of water treatment methods 3. Social influence:
– Talked to husband, husband supports, talked to others, others have recommended, has advocated to others
4. Perceived norms – Relatives or friends treating water at home
Psychosocial factors identified for water treatment in Pakistan. Sindh, 2005
0
20
40
60
80
100
0 1 2 3 4 Overall
Percent
1 817
35
66
Cumulative Number of Factors that Apply
23
Percent treating water by number of ideationalfactors. Sindh, Pakistan 2005
Factors explored: Knowledge of treatment methods, attitudes toward water treatment, social influence (talk to others), perceived norms. Adjusted for sociodemographic, water source & perceived quality & other confounders.
3
96
0.4 0.07 0.530
20
40
60
80
100
None Boiling Kaporite Filter Others
Method Used
Percent
Water treatment behavior, Water treatment behavior, IndonesiaIndonesia 20052005
Basic Health Services Survey 2006
Attitude statements identified for new Attitude statements identified for new product in Indonesiaproduct in Indonesia
1. No need to boil if there is a product that could turn unboiled water into drinking water
2. There are other ways as good as boiling to make unbolied water safe to drink
3. Kaporite is as good as boiling water to kill germs4. Kaporite is safe to turn unboiled water into drinking
water at home5. It is OK to drink unboiled water if there is a solution
one can add to kill germs in water
Measured in Binjai 2006, Sulawesi 2007 and Tangerang 2008
0.2
.4.6
.8D
ensi
ty
1 2 3 4mean(unstandardized items)
Attitudes toward new product. Attitudes toward new product. BinjaiBinjai, North , North Sumatra 2006Sumatra 2006
AgreementDisagreement
Uncertainty44%
Agreement6.0%
Disagreement49.6%
0.2
.4.6
.8D
ensi
ty
2 3 4 5mean(unstandardized items)
Attitudes toward new product. Attitudes toward new product. TangerangTangerang, , BantenBanten 20082008
Agreement31.5%
Disagreement19%
AgreementDisagreement
0.2
.4.6
.8D
ensi
ty
1 2 3 4mean(unstandardized items)
Attitudes toward new productAttitudes toward new product
0.2
.4.6
.8D
ensi
ty
2 3 4 5mean(unstandardized items)
Tangerang, 2008
Binjai, 2006 Shift in part due to regional differences butalso to the communicationabout the new product
Determinants of the Rate of Adoption Determinants of the Rate of Adoption of New Technology (Innovation)of New Technology (Innovation)
1. Attributes of the Innovation• Relative advantage• Compatibility • Complexity • Trialability (Divisibility)• Observability (Comm.)
2. Locus of Decision (Adopter)
3. Nature of Social System
4. Communication Channels
5. Change Agent Promotion
RATE OF ADOPTION OVER TIME
Source: Rogers (1995; 1962)
Attributes of the technology
Relative advantage• Is the innovation better
than the status quo? • Will people perceive it as
better?
Compatibility• Will people perceive it as
consistent with existing values, previous experiences, and needs?
“..with this product I don’t worry about accidents with kids boiling water.”
“Our water is quite safe and clean enough for us.”
Adapted containers to fit local preferences & needs
Complexity• How difficult is the
innovation to understand and apply?
• Is it too complicated?
Trialability• Can people try the
innovation or should they commit to it all at once?
PuR needs 2 buckets of 10+ liter each, scissors, a large spoon, and a cloth.
In some places, people lack utensils.
Attributes of the technology
Rp.500
Observability• How visible to others, are
the results of using the technology?
Attributes of the technology
SODIS, highly visible
Need word of mouth promotion
…and outdoor visibility
Two key implications from this model
2nd: Communication for behavior change needs strategic, integrated multimedia
approaches
PPT CCP 8/19/2008 31
•• Not Not isolated isolated posters posters and and messagesmessages……
PPT CCP 8/19/2008 32
Strategic communication is participatory…
……uses Entertainment Education to uses Entertainment Education to engage the publicengage the public
Bangladesh/Shabuj Shathi
..engages local organizations and champions…
Schools inIndonesia
Local radio in Kenya
615 PPT CCP 6/7/00 34
Soccer team, HIVprevention Africa
..get leaders’ support…
Minister of Health during AR launch
Minister of Social Welfare demonstrating AR
Role of leaders Role of leaders –– communication networkscommunication networks
Social network of women in Bojong Renged, by use of Air RahMat
Black = Never UsersRed = Ever usedBlue = Current Users
Sustained behavior more likely to happen when there are 4 elements
in place:
Four elements for sustained Four elements for sustained behavior:behavior:
• Supportive environment: policy decision-makers engaged, provide resources, media involved...
Jordan/Religious LeadersJordan/Religious Leaders
• Efficient delivery systems: services and products available, health and other services promote the behavior,..
Indonesia Blue Circlefor Private Sector Services
Air RahMat water treatment product
Four elements for sustained Four elements for sustained behavior:behavior:
• Nurturing communities: where the behavior is the norm, support groups, ownership,..
Communication Creates Communication Creates Community NormsCommunity Norms
Four elements for sustained Four elements for sustained behavior:behavior:
• Individuals and households have the motivation, knowledge, skills, attitudes, and resources to practice the behavior
Hand washing with soap in Aceh, Indonesia
Four elements for sustained Four elements for sustained behavior:behavior:
Young man using AR in Bantaeng
Photo by Abigael Ati
TerimaTerima KasihKasih!!
Photo by Ika Francisca/SWS
