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ThematicDiscussion:

Sanitationandhygienebehaviourchangeprogrammingforscaleandsustainability

DiscussionSynthesis

ByTraceyKeatman,PartnershipsinPracticeLtd.

TableofcontentsTableofcontents.........................................................................................................................1

Introduction................................................................................................................................2

Programmingforscale.................................................................................................................2Defining‘forscale’insanitationandhygieneBHprogramming.............................................................3

WhatdoesBHprogrammescale-upmeanforWASHpractitioners?Expanding?Integrating?...............3Accesstoadequateandequitablesanitationandhygieneforall............................................................3

Ingredientsforsuccessfulscale-up........................................................................................................4Stakeholders’responsibilitiesandrelationships......................................................................................4

Sustainabilityforbehaviourchange.............................................................................................5Activeconsiderationofsocialandbehaviouralnorms...........................................................................5

Contextiskey...........................................................................................................................................6Behaviourchangetechniques:examplesandchallenges.......................................................................7

Hygienepromoters–whodoeswhat?.....................................................................................................7Systemisingbehaviourchange.................................................................................................................8Designingapproaches..............................................................................................................................8

Monitoringbehaviourchange...............................................................................................................8

ODFandslippage.........................................................................................................................9ODFandslippagedefinitions.................................................................................................................9Patternsofslippage..............................................................................................................................9Localstrategiesforpreventingormitigatingslippage..........................................................................11Slippagecriticalthreshold–impactsandmonitoring..........................................................................12

Concludingcomments...............................................................................................................12

Discussioncontributors.............................................................................................................13

Referencematerials..................................................................................................................14

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IntroductionTheWaterSupplyandSanitationCollaborativeCouncilCommunityofPracticeonSanitationandHygieneinDevelopingCountries(WSSCCCoP)andtheglobalSustainableSanitationAlliance(SuSanA)cametogetherinlateSeptember2015toholdajointthree-weekthematicdiscussiononsanitationandhygienebehaviourchangeprogrammingandsustainability.Itwasthefirsttimethetwonetworkshadcometogethertohostanonlinecollaborativelearningevent.Bothplatformshaveover5,000memberseachworkinginWASHandotherrelatedsectors.Hence,thisthematicdiscussionwasanopportunitytobringtogetherthesetwoglobalcommunitiestosharelearningandtoexplorelinksbetweenresearchandpracticeonbehaviourchange.

Thediscussionwasdividedintothreeinter-linkedsub-themestofurtherexplorehowbehaviourchangecanbebetterunderstoodandimprovedtoensurehealthandWASHoutcomesaresustained.Eachweekwasledbyspecialistsineachthemewhoframedthecontentfordebateandposedstructuredquestionsfordiscussionamongstonlineparticipants.Thethreesub-themesincluded:

1. Programmingforscale–weekonefocusedondefiningscaleforsanitationandhygienebehaviourchange(BC)programming,sharingexamplesofsuccessfulscale-up(ortheingredientsthereof)andunderstandingstakeholders’responsibilitiesandrelationships;

2. Sustainabilityforbehaviourchange–thesecondweeksoughttoexplorethesocialandbehaviouralnormsanddynamicsthatinfluencehygienepractices–specifically,handwashingandtheuseofsanitationfacilities;

3. Opendefecationfree(ODF)statusandslippage–thethirdandfinalweekofthediscussionfocusedonunderstandingterminology,exploringpatternsofslippageandlocalstrategiesforpreventingormitigatingslippage.

Thissummarypaperbringstogetherkeydiscussionpointsfromacrossthethreesub-themesandcaptureskeyreflectionsoneach.Theauthorofthissynthesisactedasthethematicdiscussioncoordinatoracrossthetwoonlineplatforms;shewouldliketoexpresshergratitudetoeveryonethatsharedtheirtimeandinsightsforthisexercise.

ProgrammingforscaleSuvojitChattopadhyay,aconsultantfocusedonmonitoringandevaluation,ledthefirstsub-themebyhighlightingthatthesanitationchallengeisacomplexand“wickedproblem”.ThekeychallengefortheWASHsectoristoinducelastingbehaviourchange:

“Theverynatureofcarefulsocialengineeringrequiredtobringaboutthisbehaviourchangeseemstoruncontrarytosomeofthefactorsthatmakeaninterventionscalable–anabilitytostandardiseinputsandbreakprogrammecomponentsdowntoeasilyreplicablebits.”

SuvojitcalledforWASHsectorpractitionersto:avoidtarget-drivenhardwareinterventionswhichwillneitherchangebehaviour,norcreatesocialcohesionbuttodoconstructionwell,withusableandlastingdesignsthatpromotelocalownership;learnfromeffectivemarketing(socialorotherwise)toreacheachandeveryperson;recognisethatconventionalapproachesarenotworkingandthatthereshouldbeafocusonpersonalandenvironmentalsanitationandhygieneasawhole(notjustensuringthatcommunitiesareODF)andalsoonstarting‘atscale’ratherthansettlingforincrementalcoverage.

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Defining‘forscale’insanitationandhygieneBHprogrammingAsanticipated,therewasagoodlevelofdebatetryingtounderstandwhat‘scalingup’meansindifferentcontextsforsanitationandhygienebehaviourchange;andthereforeprogrammingforscaledependsonhavingaclear,coherentandaccepteddefinition–whichisnotnecessarilyunderstoodoragreeduponbyall.AsElisabethvonMuenchsaid:

“Sowhatisitthatwearescalingup?Purelythosethingsthatdon'trequirehardwareintervention?Actually,everything,evenhandwashingandstopping[opendefecation]ODneedssomeformofhardwareintervention.Sothatcan'tbeit.Ithoughtit'sallabouthygienebehaviourchange(mainlyhandwashingandnotdoingODwhenyouhaveatoilet)-andnotreallyaboutgettingtoiletstothepeople,right?”

Parallelsweredrawntothechallengeofdefiningscale-upinthecontextofnutritionprogrammes,AlexisD’Agostinosaid:

“…theredidn'tseemtobealotofagreementwithinourfieldofwhatthattermreallymeant.Expandingprogrammingtonewgeographicareas?Integratingitintoalocalsystem?Both?Neither?Somethingelse?”

Participantsnotedthatthechallengesinsuchcomplementarysectorsmayprovideimportantlessonsthataretransferabletoscalingupbehaviourchangeprogrammes.

WhatdoesBHprogrammescale-upmeanforWASHpractitioners?Expanding?Integrating?Toscaleuporreplicateinterventionsonalargescale,sanitationhardwaresupplyandhygieneeducation(whichcanleadtobehaviourchange)requiretailoredeffortsastheyprobablywillnothappenatthesamepacenorbecomprehendedtogetherasahealthimprovement‘package’.Thisistheprimarychallengewhenconsideringprogrammingforscale–thedifferentelementsofWASHprogrammesdonotscaleupinthesamewayorthroughthesamemechanisms.Plus,scale-upinonedimensionmaynothaveacausalrelationshipwithanother.Forexample,RolandWerchotanotedthatbehaviourchangeatscalealonewouldnotnecessarilymeanthatscaleisalsoreachedonaccesstosanitation.

AsPeterBuryhighlightedthereisaneedtodistinguishbetweenbutalsopromoteintegrationofsanitationandhygiene(wherebyhygieneeducationcaninfluencebehavioursandhygienicpractices)andnottreatthemasseparateactivities.Similarly,participantsnotedthathygienecanneverbesustainedwithoutadequatewater–sothefocusremainsonwaterquantitytoo.

“Improvementinhealthdependsthereforemoreonsanitationonceaminimumofclean(utility)waterisavailable.”(QuotefromRolandWerchota)

Dependentonthecontext,therehastobesomewateraccessintegratedwithasanitationservice(on-site,shared,household)andbehaviourchangetohavetheimpactrequired.Viewsonhowinterventionsaresequenced,whichstakeholdersareinvolvedandwholeadstheprocess(community,government,privatesector,NGOs)differedamongparticipantswhohighlightedthedifferentneedsindifferentcontexts(e.g.rural,urban,peri-urban,inschoolsorhealthcentres,post-conflict,internallydisplacedpersoncamps,etc.).

AccesstoadequateandequitablesanitationandhygieneforallThissub-themewasdiscussedduringthesameweekthattheUNGeneralAssemblycametogetherinNewYorktoagreeandfinallyadoptthenewSustainableDevelopmentGoals.Ofrelevancetothisdiscussionisthecommitmenttotarget6.2whichdemandsanaccelerationofpaceandpracticeforsanitationandhygiene:

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By2030,achieveaccesstoadequateandequitablesanitationandhygieneforallandendopendefecation,payingspecialattentiontotheneedsofwomenandgirlsandthoseinvulnerablesituations.

Themandatetoachieveaccessforallhasclearimplicationsforprogramming–itreinforcestheneedforensuringequitableandinclusiveservicesaswellasproducts,hygieneeducationandongoingsupportorfollow-upoverthelongterm.Similarly,intermsofintendedpublichealthimpact,Suvojithighlighted:

“…withouttheinclusionofallhouseholdsinacommunity,gainsfromimprovedsanitationcannotberealised.Unlessallfamiliesadopthygienicsanitationpractices,wewillnotmakeadentontheincidenceofdiseaseprevalence.”

Doesthismeanscalinguphygienicsanitationpracticesalwaysmeansreaching100percentofthepopulation?ItwasagreedthatBHcannothappenovernightbutisagradualprocessthatrequiresongoingfocusandsupportduetopopulationgrowth,peopleforgetting,andtheneedforrepeatededucationinschoolsandthroughmedia.Accessforallsurelyimpliesongoingactiontoensurechangedhygienebehavioursandpracticesaresustained.

Ingredientsforsuccessfulscale-up

Inthecasesofsuccessfulscale-up,wereprogrammesinitiatedandsustainedbygovernmentalornon-governmentalactors?Whatarethekeyelementsofasuccessfulpartnership?Howcanwestrengthennationalownership?

Therewasanexampleprovidedofhowpartnershipsandconvergentactionarecentraltoscalingup–AnandShekharsharedhowtheMinistryofDrinkingWaterandSanitation,theGovernmentofIndiaandtheGlobalSanitationFundhaveannouncedtheShillongDeclarationon‘PromotingSustainablePartnerships’.Inaddition,theprocessofachievingODFstatusinNadiaDistrictinWestBengal(seesabarshouchagar.informore)requiredthatstakeholdersshare‘keyvalues’toensuresuccessatscale.Thesevaluesincludedecentralisation,jointplanning,co-financingandcollectiveaction.

Severalpeoplecommentedonhowthereisnotaone-size-fits-allapproachandthatthereisaneedtolookbeyondtheWASHsectormore,tointegrateeffortswiththoseofothersworkingonlivelihoodsandothersectors.

Stakeholders’responsibilitiesandrelationshipsParticipantshighlightedthatsanitationBHcampaignsneedtobelocallyledandsustainedbylocalgovernmentalorcollectivecommunityresourcesplusinter-ministry,aswellascommunity,buy-inandcoordination.Achievingthisiseasiersaidthandone.Forexample,Anandnotedthat:

“Generally,programmesofdevelopmentorganisationsareguidedbyvalueswhichmayormaynotmatchandconvergewithothers.Scalingupdemandsscalingupofcoresetofvaluesthatpromotesustainabilityofbenefits.”

Giventheenormityofthechallengetoreachscalethereisarecognitionthatoneorganisationorstakeholdergroupcannotdoeverythingneededtoreachwiderscalealone.Unlessallpartieshaveanagreed,definedunderstandingofwhatitistheyaretryingtoachievetogether,itisunlikelytheywillachievetheirgoals.Thehypeandrhetoricofpartnershipsooftenconcealsthedifficultrealitiesofworkingwithotherorganisations,especiallygovernments.

Suvojitpromptedadebateontheroleofpublichealthengineers–theirroleinthedesignandexecutionofservicesandalsoforbudgetholdingratherthanthatrelatedtobehaviourchangesoftware.LalitaPulavartiprovidedanexamplefromIndia:

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“…InOrissatheExecutiveEngineers(ofajointWATSANdepartment)arestillinchargeofthesanitationprogram.However,thisdoesnotmeanthattheyarepayingattentiontostructuralordesignissues!Itonlymeanstheyareinchargeofthemoneythatflowsinthroughthescheme.Sub-contracting(andtheresultantkickbacks),andnotgivingownershiptothecitizenstogetthetoiletbuiltthemselves(duetoscaleissues/laborissues[skilledmasons,etc.]oranyotherreason)iskillingthescheme.UnlessthischangesunderSBM,wewillseemoreofthesameinIndia.”

Thereisalsoaneedtoworkmorewithnon-traditionalpartners–suchas"anthropologists,sociologistsandpsychologists"insanitationprogrammingtobetterunderstandthedeterminantsofmassbehaviourpatterns.Plus,perhapstheycanassistmoreinraisingawarenessoftheneedforsanitationandhygieneamongstpeople,notablythepoorest,whohavesomanycompetingprioritiesfortheirtimeandmoney.Suvojitalsonotedtheprominentrolethattheprivatesectorcanplayinthepromotionofhygieneandsanitationcampaignsandexpansionofprogrammes:“Whetherintheformofinnovativecommunicationcampaigns,orfinancingthroughCSR,privatesectorresourcesneedtobeharnessedthroughmutuallyfruitfulcollaborations.”

Attheendoftheweek,Suvojitprovidedreaderswithhis‘sixstepformula’toasuccessfulsanitationandhygienecampaign:

1. Donotapproachcommunitieswithasinglemessage(buildandusetoilets),butwithacomprehensivehealthandhygieneintervention.

2. Insteadofbeingsubsidy-averse,bereadytoexperimentuntilyougetthedesignright.3. Playonlocalpowerrelations.4. Allowcommunitiestoevolvetheirownnormsaroundindividualandcollectiverightsand

responsibilities.5. Donothurryintoscalingup.6. Perhapsmostimportantly,beconscientiousaboutquality.

SustainabilityforbehaviourchangeThesecondweekexploredthesocialandbehaviouralnormsanddynamicsthatinfluencehygienepractices–specifically,handwashingandtheuseofsanitationfacilities.Bywayofdefinition:

"Socialnormsaresociallyacceptedoragreedvalues,beliefs,attitudesandbehaviours–reflectingwhatapersonconsidersrightandexpectedbehaviour.Thisisrelatedtohowpeoplethinkothersexpectthemtobehave,andwhatmostotherpeopledo."(IDS,2015)

AsthepreviousweekfocusedonunderstandingwhatmightberequiredtoprogrammeforscaleinBHactivities,thesecondweekofconversationsfocusedonhowBHcanbesustainedonceprogrammesareinplace.

ActiveconsiderationofsocialandbehaviouralnormsHenrietaMutsambi,theWASHManagerattheInstituteofWater&SanitationDevelopment(IWSD)promptedthediscussionbysharingherknowledgeandexperiencesofbehaviourchangeeffortsinZimbabwe.Shehighlightedthat:

“Healthbehavioursshouldbeengrainedinone’salreadyexistingeverydayculture.Scaringtacticsdonotworkandpeopleincludingchildrendonotbelievethattheywill‘diejustlikethat’iftheydonotuseatoiletorwashtheirhands.BUTwhyarewepushingforhandwashingtohappen–toavoiddiarrhealandotherrelatedcommunicablediseases.”

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Henrietawentontohighlightsomeofthekeywaysformainstreaminghandwashingandlatrineuseinexistingsocio-culturalbeliefsandnorms.Forexample:usingreligiousscripturetoreemphasisehandwashingwithdifferentfaithcommunities;buildingontraditionalbeliefsabouthygiene(e.g.theNdebelepeopleinZimbabwedonotbelieveineatinginpublicplaceswheretherearenofacilitiessuchashandwashing);experientiallearning(showvisuallyhowhandwashingwithorwithoutsoapcleanshandsdifferentlybyusingawhitetowelforhand-drying);andthevalueoflinkinghygienetosocialstatusandconceptsofdignityandpridewhichcanworkinsomecontexts(althoughnotall).Severalcontributorsnotedthevalueofinfluencingtheyoungsothathygienicpracticesbecomeroutinebehaviour.

ContextiskeyUnderstandingtheincentivesandinternalmotivationsforbehaviourchangeiskeytodesigningbehaviourchangetechniques–suchtechniquesmustbetailoredtothecontext.Forexample,SamFrenchdescribedWaterAid’sexperienceinWestAfricawhentheorganisationwastakingwhatithadlearnedaboutCLTSfromBangladeshandtailoringitfordifferentcontexts:

“Wehadtolearnalotaboutthesocio-culturalcontextandtailorappropriately–wesoonlearntthat'shame'didnotmotivatecommunitiesinNigeriatochangetheirbehaviour,butratherpositivemotivatorssuchasthefeelingofdignityandpride.”

NabilChemalysharedhisexperiencefromtheGIZWaterProgrammeinBurundi,wherebehaviourchangeinterventionsweredesignedtotargetmainlypsychologicalfactorsandweretestedandassessedintheshortterm(onemonthafterimplementingtheintervention)andmediumterm(6monthsafterimplementingtheintervention)todeterminescale-uppotential.Thesanitationbehaviourchangeinterventionsconsistedofacombinationofthefollowinginitiatives:

• Awarenesssessionstohouseholds+trainingforlocalconstructionworkers+in-kindsubsidiesupto50%ofthecostofalatrine;

• Awarenesssessionstohouseholds+trainingforlocalconstructionworkers+assistanceinhouseholdfamilyplanningtosaveenoughmoneyfortheconstructionofalatrine;

• Awarenesstohouseholdsthroughtheatreasameansofmasscommunication+trainingsforlocalconstructionworkers.

Nabilnotedthatmanyotheractivitieswereundertakentocreateanenablingenvironmentforthesuccessoftheseinterventionssuchastraininghealthpromoterstoconductawarenesssessions,trainingpharmaciststoproducechlorine,traininglatrineconstructionworkersandplumbers,buildingdemonstrationlatrinesinpilotareas,etc.Theshort-termevaluationofsanitationinterventionsshowedmanyvaluablelearningpoints,includingthat:theatreasameansofmasscommunicationdidnothaveamajorimpactonaccesstosanitationandthereforehasalimitedpotentialwithoutconsistentfollow-up;awarenessusinglocalagentsisaneffectivetechnique,butproperfollow-upandmonitoringfromlocal,provincialandcentralsanitaryauthoritiesisnecessary;and,thefirstawarenesssessionstohouseholdsweremoreeffectivethanfollow-upsessionsplannedaccordingtotheapproachproposed.

Asnotedinweek1,BHisalong-term,slowprocessthatdoesnothappenuniformly–additionally,severalcontributorsnotedthatthetimelimitsofmanylocalNGOinterventionsaretooshort.Similarly,FranckFlachenbergnotedthatsomeprogrammes“justjumpfrombehaviourchangeobjectivesstraighttotheactivities,withoutgivingmuchthoughttowhypeopledowhattheycurrentlydoandwhatmaybepreventingthemfromadoptingthehygienebehaviourspromoted.”Analysisby3ieshowedthat:

"Barrierstobehaviourchangedependonthestageoftheproject.Manystudiesassessthehealthbenefitsofinitialuptakeofsafewater,hygieneandsanitationtechnologiesand

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practices.Butfewstudiesconsidersustaineduse.Theearlyprojectperiodmaybecharacterisedbyenthusiasmoverthenewtechnologyorpromotionalactivities.Althoughexternalsupportendsduringtheearlypost-projectperiod,thepromotionalmessagesmaystillbefreshinpeople’sminds.However,influentialhouseholdmemberswhowerescepticalmayreasserttheirdominationduringthisphase.Andfinally,inthelatepost-projectperiodstockouts,technologyfailureorpoormaintenancesystemscanposeaseriousthreattosustainedadoption."

The3ie-supportedsystematicreviewalsofoundthat:

"...frequent,personalcontactwithahealthpromoteroveraperiodoftimeisassociatedwithlong-termbehaviourchange.Thereviewsuggeststhatpersonalfollow-upinconjunctionwithothermeasureslikemassmediaadvertisementsorgroupmeetingsmayfurtherincreasesustainedadoption."

IWSD,GIZ,ConcernWorldwide,WaterAidand3iecontributionsallhighlightedthevalueoftakingaholistic,multi-prongedapproachtoincreasethepotentialforBHtobesustained.Wherethereisinformation,educationandcommunication(IEC)providedtocommunitiesinvariousmediapluspracticalsupporttoensurethereisanenablingenvironment,thetechniquesusedappeartohavemorechanceofsuccessandmaybebettersustained.Hence,usingtoolsthatmoresystematicallyanalysebarriersanddriverstowardsBHshouldbeplannedintoprogrammesfromthestart,andsubsequentBHcampaignsshouldbebasedonthecontext.

Behaviourchangetechniques:examplesandchallenges

Hygienepromoters–whodoeswhat?FranckFlachenbergsharedConcernWorldwide’sapproachtohygienepromotion,highlightingthatmanyWASHprogrammesrelyontraininghygienepromoterswhoareusuallymembersofWASHcommitteesthathavebeensetuptomanageinfrastructure.Franckarguedthatforsustainabilitypurposesitwouldbebettertorelyonexistinglocalnetworks,suchascommunityhealthworkers,andthathygienepromotionshouldbeintegratedasmuchaspossiblewithintheexistinghealthsystemratherthansettingupparallelsystemssuchasWASHhygienepromoters.

JihaneRangamaagreed,providinganexamplefromBurkinaFaso,wherehygienepromotionactivitiesareperformedbylocalvolunteers(membersoflocalwomen'sassociationsforexample).However,feedbackshowedthatthevolunteers’motivationdecreasedquitequickly,andtheresultsintermsofbehaviourchangeinterventionswerenotasgoodasexpected.SamFrenchaddedthatcrosssectorintegrationisalsokeytoamulti-prongedapproachwherebyschools,healthcentres,midwives,etc.alluseandreinforcethesamemessages.

TomDavissuggestedhoweverthatthefocusonusingpaidprofessionalsforhealthpromotionisunfoundedandreferredtoresearch1thatfoundthatprojectsusingCareGroupshaddoubletheadoptionofhandwashingwithsoapasprojectsthatdidnotuseCareGroups.CareGroupsrelyonvolunteers.SusanDavisalsocontributedtothispointbyhighlightingastudythatcomparedCLTStotheCommunityHealthClubsapproach(WhaleyandWebster,2011).

"Whilstbothapproacheseffectivelyencouragedmeasuresthatcombatopendefecation,onlyhealthclubswitnessedasignificantincreaseintheadoptionofhandwashing.However,CLTSprovedmoreeffectiveinpromotinglatrineconstruction,suggestingthatthe

1Georgeetal,2015EvaluationoftheeffectivenessofcaregroupsinexpandingpopulationcoverageofKeychildsurvivalinterventionsandreducingunder-5mortality:acomparativeanalysisusingthelivessavedtool(LiST),JohnHopkinsBloombergSchoolofPublicHealth,USA.Availableat:http://www.biomedcentral.com/1471-2458/15/835

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emphasistheCHCsplaceonhygienepracticessuchashandwashingneedstobecoupledwithanevenstrongerfocusontheissueofsanitationbroughtbyCLTS."

SystemisingbehaviourchangeWaystosystematisebehaviourchangetechniquesandtounderstandsocialnormshavebeendeveloped.OnesuchsystemwassharedbyProfessorHans-JoachimMoslerfromEawag–the“RANAS”frameworkthatseekstoprovideaprocessforsystematicallymappingpotentialbehaviouraldeterminants(basedonhumanpsychology)andthenlinkingthempracticallytospecificbehaviourchangetechnologies.Withsuchframeworks,practitionersareabletodevelopatailored,context-specificapproach.TomDavisalsoreferredreaderstothedifferentdeterminantsfoundforthe18BarrierAnalysisstudiesonhandwashingwithsoapshownontheFoodSecurityandNutritionNetwork'sBehaviorBank.

DesigningapproachesProfessorMosleralsopointedoutthatdesigningcontext-specificapproachescouldbebetterdonebyengagingwithcreativeagencies–whowouldalsohavetounderstandthecontextandaudience–whichisanapproachthatmanyprivatesectororganisationsuseforbehaviourchange.ItwasnotedthattheWASHsectorcoulddomoretobetterunderstandandlearnfromtheprivatesectorabouttheirexperiencesandexpertiseonthebasicmechanismsorstructuresbehindthedesignoflarge-scalebehaviourchangemediacampaigns.ThisistoensurethesedesignprinciplesarecoherentlyaddressedinthedesignofWASHprogrammesandcomplementwhateverishappeningonthegroundonpersonalhealtheducationandfollow-up.

Havingacomplementaryapproach(massmediapluslocal,sufficientlylong-termsupportandfollow-up)canclearlyreaprewards(asnotedabove).Yet,howisthissystematicallyplannedforanddeliveredinaprojectorprogrammecycle?HygienebehaviourchangerarelyseemstobeelevatedtothissystematicplanningstatusinWASHprogrammes–despitetherecognitionofitsimportance.Italsorequiresustoworkinpartnershipwithothersthatwemaynotusuallyengagewith(ashighlightedearlier).

MonitoringbehaviourchangeIntermsofmonitoringandevaluatingBH,Franckalsohighlightedthat“arobustM&Esystemisassociatedtoeachnewcampaignsoastobeinpositiontoassessitsresultsintermsofeffectivebehaviourchange(andnotjustimprovementinknowledge).”

TakudzwaNoelMushambahighlightedthatthe“absenceofcasesorlowprevalenceofwaterandsanitationdiseasesisnotnecessarilyandindicatorof‘improvedbehaviour’”.Hedrewattentiontotheepidemiologictriangle,whichshowsthelinkagesbetweentheagentofdisease,thehostandtheenvironmentnotingthat:

“Wearemoreaproductoftheenvironmentthanwhatpeopletellus.Thesamemessagemeansdifferentthingstotwopeople.Tooneitmeansopenthetapandahandsanitizerandtoanotheritmeansbuyextrasoap,traveltoaborehole8kmawayandgetanextrabucketofwaterandwashbeforeyoueat.Infrastructureplaysahugerolenotonlyinreducingexposurebutalsoinfosteringnewbehaviour.”

Finally,HannaWoodburn2fromThePublic-PrivatePartnershipforHandwashing(PPPH)notedthatduringUNdiscussionsontheadoptionoftheSDGs“whenbehaviourchangewasmentionedasbeingkeytoachievingthesegoalsresponseswereoftenabstract”.

2HannaalsodrewparticipantsattentiontothePPPHHandwashingBehaviourChangeThinkTankeventheldatAfricaSan4inDakar,Senegal,whichlookedatthreebigideasinhygienebehaviourchange:emotionalmotivators,behaviouralsettings,andthescienceofhabit.

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Somonitoringeffortsalsoneedtobemulti-faceted,holisticandabletochangealongwithcontextualchangesandthestagesofparticularprogrammes.

ODFandslippageInthethirdandfinalweekofdiscussions,theconversationmovedontoaddresswhathappenswhenchangedbehaviours‘slipback’orwhereBHprogrammesmayrequireextrasupport.ColleaguesfromtheGlobalSanitationFund(GSF)thatledtheweekhighlightedthefollowing:

“Large-scalebehaviourchangeorientedsanitationprogrammesoftenfocusonsupportingcommunitiestoachieveopendefecationfree(ODF)status,criteriaforwhicharelocallydefinedbutoftenincludeacompletestopofpeopledefecatingintheopen,accesstobasicbutfly-prooflatrinesforallcommunitymembers,andpresenceofhandwashingstationswithwaterandsoaporashclosetothelatrines.AstheseprogrammesmatureandwhenthechallengeshiftsfrombringingcommunitiestoODFtosustainingtheirODFstatus,manyareconfrontedwiththeissueofslippage–areturntopreviousunhygienicbehavioursoraninabilityofsomeorallcommunitymemberstocontinuetomeetallODFcriteria.However,thereisalackofclarity(oratleastacceptable/universaldefinitions)ofwhatslippageactuallyisandthereisnopanaceaforhowtocometotermswithslippage,whichisdynamicandcontextspecific.Whatwedoknowisthatslippageisanexpectedaspectofsanitationinterventions,especiallythoseatscale,andNOTasignofafailurethereof.”

ODFandslippagedefinitionsTworelevantcommentsweremadeinconnectiontoGSF’sdefinitionofODFandslippage.KimberlyMcLeodagreedwiththethreemainprinciplesforrecognizinganODFvillageandreinforcedthatthe“presenceofhandwashingstationswithwaterandsoaporashclosetothelatrines”shouldgofurtherandstatethatvillagersmustalsobe“washinghandsproperlyatcriticaltimes.”AkhileshGautamalsoreflectedonwhattimeperiodcouldbeconsideredforhavingachievedODFstatusasa“stable–sustaineduse”ofatoiletbeforebeingconstruedas‘slippage’.AkhileshnotedthatinhisfieldexperienceinIndia:

“Inmanyvillagesthe"stable"periodofsustainedbehaviouroftoiletusewasneverachievedinthefirstplaceandthereforecallingitslippageiserroneousandhasdifferentimplicationsforstrategycoursecorrectioninthesanitationprogramming.”

Patternsofslippage

“Sanitationandhygienebehaviourchangeisanon-linearprocessthatmightlooklikethis:acommunityistriggered,endeavorstoreachODF,isdeclaredODF,slipsbackrepeatedly(duetovariousindividual/collectiveandinternal/externalfactors)tonon-ODFstatusfollowedbyinterventionstoregainODFstatus.Acommontrendseemstobethatthemoreofteninterventionsarerepeatedandfollow-upsupportisprovided,thelessdramatictheslippagewillbeuntileventuallyalevelofmaturityismetandbehaviours‘stick’.”(GSFcolleagues)

IntermsofODFslippageexperiencedindifferentprogrammesaroundtheworld,therewasaninterestingselectionofreasonsforandpatternsofslippage–someofwhichwereexternalinfluencingfactors(e.g.socio-cultural,environmental,financialandpoliticalaspects)andsomewhichsanitationandhygieneprofessionalsmayhavemorecontrolover(e.g.poorlydesignedprogrammesorprogrammaticlimitations).ThefollowingbulletpointssummarizethekeyODFslippagefactorssharedbycolleaguesonbothdiscussionplatforms:

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Ø Socio-culturalaspects–communalconflict;IDPs’needsandimpactonavailablelocalfacilities;vulnerablepeopleunabletomeetODFwhichimpactsonallcommunity;lackofpeerpressurefromcertifiedODFcommunitiestotheircolleagues;

Ø Environmentalaspects–seasonalorotherflooding(leadingtolossoflatrines,fewerpossibilitiesforfollowupbyfacilitators);toomuchrainsolessashforhandcleaningandcleaninglatrines;

Ø Financial/economicaspects–affordabilityofsuitablehardwarebytheurbanpoor;poormanagementoffundsforBHandrelatedfollowup;

Ø Politicalaspects–“Unhealthycompetitionbetweenlocalgovernmentstomeetcentralgovernmenttargets,atall(non-financial)cost”;

Ø Programmaticlimitations–o Poororweakcommunity-ledtotalsanitation(CLTS)triggeringfacilitation;o Unclearmessagingonhygieneandpoordeliveryofmessages,e.g.peopleopenly

defecateoutsidetheircommunityforconvenienceindicatingthatthemessageisnotfullyunderstood,thatthere’salackofawarenessandmotivation,orthatthemessagehasnotbeenpassedontotheentirefamily/householdandlowlevelsofactualandengrainedbehaviourchangeduetolowqualityimplementation;

o Hastyandlowqualitybuildingoffacilitiesthatdonotmeetnationalstandardsandwherethereisnopost-constructionmaintenance/repairsprovision;unequalorinconsistentsupplyofhardwarefacilitiestomeetdemandorunsuitable,inappropriatesanitationfacilityforthecontext;

o Lackofsufficientand/orwell-fundedfollow-up,e.g.supportstructures,maintenance/repairoptions,bygovernment,environmentalhealthstaffornaturalleaders,etc.;

o Lackofsufficientengagementofthemunicipality.

CarolienvanderVoordensharedlearningfromMadagascarthatindicatedthatsanitationandhygienepractitionersmustacceptslippageasinevitableandrespondwithtoolsandapproachestokeepencouragingbehaviourchange.Indeed,muchlikewatersupplyandaccesstolatrines,ODFandrelatedhygienebehaviourchangemustberegardedasan‘ongoingservice’andnotjustaone-off,supply-ledeventorintervention.

Again,rolesandresponsibilitiesofkeystakeholdersneedclarificationtosupportandmanageODFstatus.Forexample,JoséaRatsirarsonhighlightedtherolethatWASHpractitionerscanrealisticallyplayinsupportingODF:

“Onceidentified,facilitatorsshouldhelpthecommunitytofinditsownsolutionratherthanbringingexternalsolutionstothem.We,asexternaltothecommunity,cannotjustsolvenorhaveallthesolutions.Theproblemcomesfromwithinthecommunityandthereforethesolutionshouldbecommunity-led,ourroleistofacilitatetheprocessoffindingtheseinternalsolutions.”

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LocalstrategiesforpreventingormitigatingslippageSeveralinterestinglocalsolutionsweresuggestedbyNanpetChuktufromhisexperiencesinNigeria–allofwhichrelatetoconsistentandclearfollow-upactivitiestomaintainchanges.Hissuggestionsincluded:

Ø WASHClinics–whichbringtogetheragroupofvillages(20-30)thathaveacommonheritageofadministrativeaffinity.Anappraisaloftheperformancesofthecommunitiesismadeandthoseperformingwellarepraised;

Ø LocalTaskGrouponSanitation–forexample,alocallybasedgroupofseniorstaffoftheLocalGovernmentAuthority,religiousleadersandtraditionalleaders.TheyhavebeentrainedontheNationalODFverificationprotocolandthecriteriaexpected.TheirroleistoconductmonthlyverificationofODFcommunitiesandhavebeenusedtoadvocateto'stubborn'orlaggingcommunities;

Ø WASHCOMS–whenacommunitybecomesODF,theyaresupportedtoformaWASHcommittee(atleast6menand6women).ThesebecomethevanguardsintheirrespectivecommunitiestosustaintheODFstatus.TheseWASHCOMSnowseektoensurethathouseholdsaresupportedtohavelatrinesthatmeettheODFcriteria,helptheagedandwidowswhootherwisecannotbuildoneforthemselves.

KamalKarandteamattheCLTSFoundationprovidedacasestudy(abridged)onKalyaniMunicipalityinWestBengal,whichwasdeclaredthefirstODFurbantowninIndiain2009.

AspartofaDFIDfundedproject,apilotwasundertakenin5slumsinKalyaniin2006atthetimewhenODwasrampantintheseslumcommunitiesandfreedistributedtoiletsremainedabandonedeverywhere.UnlikeruralCLTS,theinterventionbeganatthemunicipalcouncillevelinvolvingtheChairmanandWardCouncillorsbelongingtodifferentpoliticalparties.Oncetheneedfortheinvolvementofthelocalcommunitywasunderstoodandlocalpowerrelations/equationsweresortedout,communitytriggeringwasfacilitated.Thisinvolvedallformal/informalleadersofaparticularslum.Themunicipalitywascompletelyinvolvedinthetriggeringprocessandposttriggeringfollowup.

Within6months,these5slumsweredeclaredODF.Soon,aspillovereffectwasseeninotherneighbouringslumsaswellandby2009allofthe51slumsintheMunicipalityweredeclaredODF.ThisrapidscalingupwasonlypossiblebecauseofthecollectiveactionthatwasgeneratedwithinthecommunitiesandthenaturalleaderswhoemergedduringthisprocesswhoensuredthatalltheslumsweremadeODF.However,therateofprogressofalltheslumswasnotthesamebecauseofthevariednatureofinvolvementandcommitmentofdifferentwardcouncillors.

After6yearswesawthatthecommunitieshavemaintainedtheirODFstatusandmanyofthemhaveupgradedtheirtoiletsusingtheirownmoney.ItisimportanttonotethekeyfacilitatingrolethattheMunicipalityplayedinthisentirechangeprocess.DuringthetriggeringtheyallowedthecommunitytotaketheleadandmadesurethatthemessagesforcollectivehygienebehaviourwassustainedthroughtheHonoraryHealthWorkers(HHW)whobelongedtothecommunityinthefollowupstages.Kalyaniisaclearexamplethatforcomprehensivesanitationplanningandimplementationinurban/peri-urbanareas,thefullparticipationandengagementofallstakeholders,particularlythelocalcommunitymembersatallstagesofplanningandservicesdelivery,isessential.

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DennisAlionidiscussedalocalstrategyusedbytheWaterandSanitationPrograminUganda,whichincludedCLTStriggeringaspartofawider,holisticinitiativethatseekstoimprovetheenablingenvironmenttoo(e.g.byintroducingentrepreneursandfinancialinstitutionsintothemix“toprovideservicesandaccesstofinanceforimprovedfacilities”).Thiswasaccompaniedbydemandcreationactivities.

JoséaprovidedanexamplefromMadagascarabout‘livingbyanODFspirit’–whichoccurredwhengoodfacilitationandeffectivesupporttogenerateadeepunderstandingofthebenefitsofODFstatusledtoacommunityinBoenyRegionbeingabletorebuildtheirlatrines(ontheirown)afterapowerfulcyclone.

Slippagecriticalthreshold–impactsandmonitoringMatildaJerneckandcolleaguesattheGSFaskedwhetherthereisacriticalthresholdforwhenslippagehasanimpactonthesocialorhealthstatusofthecommunityandhowslippage,asadynamicprocess,canbemonitored.Severalcontributorsnotedthatsometypesofslippageare“morecriticalthanothersdependingonthecontext”.

Asregardshowslippagecanbemonitored,therewasagreementthatwaysofmonitoringdoneedtochangeduetothedynamicprocessofslippageandchangedbehaviours.Thereisaneedtobemoreinterrogativeandanalyticaltounderstandwhyslippagehashappenedinordertoinformthenextsteps.Plus,notallindicatorsofmeasuringODFstatusare‘equal’–theyalsomustbeunderstoodwithinthelocalcontextandresponsesmustbetailoredaccordingly.Kimberlysuggestedthat:

“ThereisastrongneedtodeveloparobustevaluationsysteminordertomaintainthestatusofanODFvillage.InadditiontosustainingtheeverydayroutineofanODFvillage,onemustevaluatethevillagetodeterminewheretheissuesareoccurringorevenwheretheyareexcelling.[…]Weproposetoaskmoredirectquestionssuchas‘Whyisthisvillagefailing?’,‘Whereisthevillagefailing’,and‘Whatisthefrequencyoffailure’.Thisway,wecanbetterpinpointthenextstepsofhowtogetthevillagebacktoODF.

ConcludingcommentsOverall,thecommentsmadeindicatedthatthereisstillalottolearnabouthowtoplanforat-scaleBHprogrammesthateffectivelylinktolocalsocialandbehaviouralnormsandinformBHtechniquesindifferentcontexts.Thediscussionprovidedanopportunitytosharesomerecentandrelevantlessonslearnedfromparticipants’differentexperiencesandprogrammes.Intermsofintegratinglearningtoimproveinterventions,bothKimberlyandKamalimpliedthatthereisaneedtocontinue‘learningbydoing’.

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DiscussioncontributorsSuvojitChattopadhyay,consultantfocusedonmonitoringandevaluationAnandShekhar,TeamLeaderatNRMC,ExecutingAgency,GlobalSanitationFundinIndiaKitchinmeBawa,WSSCCSteeringCommitteemember:Middle/Northern&WesternAfricaPeterJ.Bury,Consultant,DevelopmentProcessesAlexisD'Agostino,M&ESpecialistatJohnSnowResearchandTrainingInstituteRolandWerchota,GIZAishaHamza,Sanihygeducationinitiative(SAHEI)AnwerSahooly,SeniorInstitutionalDevelopmentConsultant(freelanceconsultantatGIZ)LalitaPulavarti,SeniorManager,ProtectsatPublicAffairsFoundationGodwin,aWASHSpecialistandConsultantHiteshChakravorty,IndiaHenrietaMutsambi,WASHManager,InstituteofWater&SanitationDevelopment(IWSD),ZimbabweNabilChemaly,GIZWaterProgramme,BurundiFranckFlachenberg,EnvironmentalHealthTechnicalAdvisor,ConcernWorldwideChhabiGoudelSamanthaFrenchJihaneRangama,TechnicalAssistant,GIZWater&SanitationProgramHannaWoodburn,TheGlobalPublic-PrivatePartnershipforHandwashing(PPPH)EdithKamundiProfHans-JoachimMosler,EawagTakudzwaNoelMushambaTomDavis,ChiefProgramOfficer,FeedtheChildrenSusanDavis,ImproveInternationalNiveditaMahotra,UrbanManagementCentre(UMC)TraceyKeatman,PartnershipsinPracticeMatildaJerneck,GlobalSanitationFundCarolienvanderVoorden,GlobalSanitationFundClaraRudholm,GlobalSanitationFundKimberlyMcLeod,MedicalCareDevelopmentInternationalAkhileshGautam,SanitationforAllinIndia,GIZNanpetChuktu,ConcernUniversal,Nigeria–GSFExecutingAgencyJonathanEkhator,ConcernUniversal,Nigeria–GSFExecutingAgencyVincentOuma,AMREFHealthAfrica,Kenya–GSFExecutingAgencyMarijnZandee,NepalBiogasPromotionAssociation,GIZAdityaSoni,UrbanManagementCentre,IndiaOrlandoHernandez, USAID-fundedWASHplusProjectTobiasOmufwoko,WSSCCNationalCoordinator,KenyaDennisAlioni,UgandaJoséaRatsirarson,MedicalCareDevelopmentInternational,MadagascarPanditThakur,NepalKamalKarandteam,CLTSFoundationMinistryofHealth,UNICEFandWSSCC/GSF,BeninRenukaBery,WASHplusProject

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ReferencematerialsCavill,S.withChambers,R.andVernon,N.(2015)‘SustainabilityandCLTS:TakingStock’,FrontiersofCLTS:InnovationsandInsightsIssue4,Brighton:IDSwww.communityledtotalsanitation.org/reso...nd-clts-taking-stock

Coffey,D.,Gupta,A.,Hathi,P.,Khurana,N.,Spears,D.,Srivastav,N.andVyas,S.(2014)RevealedPreferenceforOpenDefecation:EvidenceFromaNewSurveyinRuralNorthIndia,SQUATWorkingPaper1,RiceInstitute,riceinstitute.org/research/revealed-pref...onger-working-paper/

GSFProgressReport2014:wsscc.org/resources-feed/global-sanitati...gress-report-2014-3/

GSFProgressReportMid-yearUpdate2015:http://wsscc.org/resources-feed/global-sanitation-fund-progress-update/

GSF(2015)'SanitationandHygienePromotioninMadagascar':wsscc.org/2015/10/02/learning-progress-a...otion-in-madagascar/

Hanchett,S.,Krieger,L.,Kahn,M.H.,Kullmann,C.andAhmed,R.(2011)Long-TermSustainabilityofImprovedSanitationinRuralBangladesh,Washington,DC:WorldBankwww.communityledtotalsanitation.org/reso...ion-rural-bangladesh

Mosler,H-J.,Huber,A.,Inauen,J.andTobias,R.(2012)'Howtoachieveevidence-basedbehaviouralchange',SandecNewsIssue13,Switzerland:Eawag/SandecPleaseseetheattacheddocument.

O’Connell,K.(2014)WhatInfluencesOpenDefecationandLatrineOwnershipinRuralHouseholds?:FindingsfromaGlobalReview,WaterandSanitationProgramWorkingPaper,WashingtonDC:WorldBank,www.wsp.org/sites/wsp.org/files/publicat...anitation-Review.pdf

Oddsdottir,F.(2014)Evaluationsofscalingup,GSDRCHelpdeskResearchReport1097,GSDRC:UniversityofBirminghamhttp://www.gsdrc.org/docs/open/HDQ1097.pdf

PresentationonSystematicBehaviorChange,Prof.Hans-JoachimMosler,Eawag-pleaseseeattachedpresentation.(www.eawag.ch/)

Taylor,B.,(2013)Effectiveness,ScaleandSustainabilityinWASHProgrammes–AReview,SpringfieldWorkingPaperSeries(2),TheSpringfieldCentre,Durham.http://www.springfieldcentre.com/wp-content/uploads/2013/10/2013-10-Effectiveness-Scale-and-Sustainability-in-WASH.pdf

Tyndale-Biscoe,P.,Bond,M.andKidd,R.(2013)ODFSustainabilityStudy,FHDesignsandPlanInternational,www.communityledtotalsanitation.org/reso...inability-study-plan

UNICEF(2014)EvaluationoftheWASHSectorStrategy“CommunityApproachestoTotalSanitation”(CATS),UNICEF,www.unicef.org/evaluation/files/Evaluati...RSION_March_2014.pdf

USAID(2011)At-ScaleHygieneandSanitationExperiencesandLessonsLearned,USAIDHygieneImprovementProject,TheAcademyforEducationalDevelopment,WashingtonD.C.http://www.hip.fhi360.org/file/29832/HIP%20At-Scale%20Hygiene%20and%20Sanitation%20-%20Experiences%20and%20Lessons%20Learned.pdf

WaterandSanitationProgram(2012)WhatDoesItTaketoScaleUpRuralSanitation?WaterandSanitationProgramWorkingPaperserieshttps://www.wsp.org/sites/wsp.org/files/publications/WSP-What-does-it-take-to-scale-up-rural-sanitation.pdf

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Wilbur,J.andJones,H.(2014)‘Disability:MakingCLTSFullyInclusive’,FrontiersofCLTS:InnovationsandInsightsIssue3,Brighton:IDS,www.communityledtotalsanitation.org/site...ue3_Disabilities.pdf

Websites:

UNICEF:www.unicef.org/wash/index_43107.html

TheGlobalPublic-PrivatePartnershipforHandwashingavailablehere:globalhandwashing.org/resources-main/

3ie:http://blogs.3ieimpact.org/making-wash-behaviour-stick/

UNILEVERdesignadviceformassmediacampaigns:https://www.unilever.com/Images/slp_5-Levers-for-Change_tcm13-387353_tcm244-409796.pdf

http://www.biomedcentral.com/1471-2458/15/835

http://www.fsnnetwork.org/behavior-bank

InterestingrelatedstudybyWhaleyandWebster(2011)comparingCLTStoCommunityHealthClubsapproach:www.iwaponline.com/washdev/001/0020/0010020.pdf

ShillongDeclaration:Promotingsustainablepartnerships(2015)http://www.mdws.gov.in/sites/upload_files/ddws/files/Shillong_Declaration.pdf

OnthesanitationeffortsinNadiaDistrictinIndia:http://sabarshouchagar.in

Ondefiningscaleinnutritionprojects:https://www.spring-nutrition.org/publications/briefs/defining-scale-nutrition-projects

Ongoingtoscaleonnutritionbehaviour:http://finalmile.in/behaviourarchitecture/category/social-behaviour

Onthelinkbetweenmalnourishmentlevelsandsanitationcoverage:TheResearchInstituteforCompassionateEconomics:http://riceinstitute.org/

OneffectivenessofaruralsanitationprogrammeinOdisha,India:http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(14)70307-9.pdf

OnimprovingconsumervoicesandaccountabilityinOdishaandTamilNadu,India:http://pacindia.org/uploads/default/files/publications/pdf/aaf68c1db435342f0cd6bd77fb9d31c7.PDF

OnaprivatesectorinitiativefundedbyInfosysinKarnataka,India:http://parishudh.sedam.org/