Behavior-Centered Approaches to Improve Health Outcomes: WASHplus Learning Brief

“..promoting improved behaviors without addressing shortcomings in the products and services required to practice the behaviors makes change difficult, if not impossible.”

This technical brief presents the WASHplus approach to behaviour change which is made up of a hybrid of several schools of thought and practice. The WASHplus project supports healthy households and communities by creating and delivering interventions that lead to significant improvements in access, practices, and health outcomes related to water supply, sanitation, and hygiene (WASH) and household air pollution (HAP). This involves facilitating better access to hardware and services, as well as working to influence consistent and correct practice of WASH and clean cooking behaviours, such as safe disposal of faeces, safe storage of water, and hand washing at critical junctures. Led by FHI 360 in partnership with CARE and Winrock International, the project is working in Bangladesh, Benin, Kenya, Madagascar, Mali, Uganda, and Zambia.

The brief explains that the WASHplus approach draws on a variety of behaviour theory and evidence from previous programme experience. “Our cross-cutting approach is grounded in systems thinking and the social ecological models that nurture human growth and development, through manipulating the complex, interacting, and interdependent elements that form the whole system. Social ecology acknowledges the influential role that social, institutional, cultural, and policy contexts have on individual action and the multiple levels of influence - individual, family, institutional - at play at one time. The science of habit formation, in addition to a focus on harnessing social norms, contributes to consistent and sustained practice of WASH behaviors.”

The brief offers an overview of the individual theoretical elements that contribute to the hybrid strategy.  The theories, in brief,  are as follows (described in detail in the brief with examples from practice in WASHplus programme countries):

The WASH Improvement Framework, or WIF - This is the WASHplus project’s underlying change framework. It posits that to realise sustained WASH improvement, three key domains must be engaged: 1) Access to hardware and services, such as water supply, soap, sanitation products, and financial products like loans, 2) An enabling environment, which includes a supportive policy environment, institutions with the needed capacities, coordinated planning, and budgeting, 3) Hygiene promotion and demand creation that includes social mobilisation, community participation, community-led total sanitation (CLTS), social marketing, and behavoiur change communication (BCC).

Systems Thinking - Working to complement WIF, another component of WASHplus’s change approach is systems thinking, which harnesses the interconnectedness within ecosystems and facilitates collaboration and coordination. “A central concept of systems thinking is the concept of “bridging and bonding” — bridging across different sectors (e.g., private commercial sector, health, water, education, youth, law enforcement divisions of the public and NGO sectors) and bonding or strengthening coordination within the same sectors (e.g., hygiene and nutrition coordinating within the health ministry; or NGO and government water projects synchronizing in a region). This bridging/bonding concept facilitated WASHplus’s application of the WIF to ensure all domains could be addressed, even when beyond the scope and budget of WASHplus activities.”

The BEHAVE Framework - incorporates a Hypothesis of Change into WASHplus activities. It is  driven by activities targeting priority audience segments; and addresses clearly identified behavioural determinants, which are the enabling and barrier factors most influential in the performance or nonperformance of a given behaviour for a particular population segment.  Programme activities then strategically address the particular key determinants.

Stages of Change (or the Transtheoretical Model) - in this model, change is a process involving progress through a series of stages: starting to contemplation, preparation, action, and maintenance (some have added relapse). Different factors motivate behaviour at various stages of behaviour change, and WASHplus programmes are designed to adapt to the particular stages that individuals, households, or communities have achieved.

Small Doable Actions - This WASHplus behaviour change strategy is also built around the evidence that people can rarely go directly from their current practice to ideal practice, for example, from open defecation to consistent use of a flush toilet. Rather than promoting the ideal WASH practices, WASHplus constructs a continuum of behaviours that span from unacceptable to ideal, identifying small doable action between the two. 

The Science of Habit- The science of habit tells us that goal-directed behaviours are managed by a different part of the brain than habitual behaviours. In 2012, WASHplus began exploring whether work on the science of habit formation could be applied to consistent and sustained handwashing improvement. It looked at making handwashing move from a conscious, goal orientated action to an action that was performed with little or no conscious thought. 

Because the approach is a hybrid of several schools of thought and practice, this brief also highlights principles of behavior-centered approaches to further examine how WASHplus worked to influence WASH behavior change.  Each of the theories are therefore structured according to how they fit in with these principles. 

Principle 1: Sustained practice of improved WASH behaviours requires a comprehensive approach that is multi-layered and addresses multiple domains.  WIF and systems thinking falls within this principle.

Principle 2: Behaviour-centered approaches are organised around a hypothesis of change, recognising that WASH behaviors (all behaviors, in fact) are influenced and maintained by a set of context-specific internal and external determinants.  The BEHAVE Framework falls within this principle.

Principle 3: Behaviour-centered approaches require research to shape programming. Various research methods systematically identify behavioural determinants, help explain audience context, and hone in on emotive factors that influence behaviors. This research may be original or findings applied from previous, relevant research.  Here the brief looks more closely at WASHplus’ research approaches, such as Trials of Improved Practices (TIPs),  making the point that “existing data and information, together with project-generated insights, are essential to plan comprehensive behavior change strategies.”

Principle 4: Behavior-centered approaches accommodate relevant behavioural options, starting from one’s current context (or stage) and negotiating small, doable improvements toward ideal WASH practices. The Stages of Change theory and Small Doable Action theory fall within this principle.

Principle 5: Behavior-centered approaches reach to the reflexive mind responsible for habits, as well as the reflective, conscious, and deliberate mind. The ideas emerging out of Science of Habit Formation theory fall within this principle. 

The brief concludes by making the point that the greater WASH community needs to continue efforts to address key determinants for behaviour change using tested and innovative approaches. For example, “the recent infusion of habit strategy into WASH behavior change work offers particular promise that still needs further testing and assessment to understand whether and how this approach can sustainably change the way people practice hygiene.”