Department Environmental Social Sciences

Using persuasive arguments to change perceived costs and thus consumption of safe water in Ethiopia

Project description

Fluorosis is caused by undue fluoride uptake from drinking water. In the Ethiopian Great Rift Valley, the consumption of fluoride-free water from a community filter was promoted by a) a traditional information intervention targeting perceived vulnerability, and b) a systematic behavior change strategy targeting perceived costs. While the intervention targeting perceived vulnerability showed no effects, cost persuasion decreased the perceived costs to a 50% lower value and increased the consumption of fluoride-free water by 20%. This showed that altering subjective perceptions of facts like prices or walking distances can change behavior even without changing objective circumstances.

 

Context
Around 200 million people worldwide rely on drinking water that is contaminated with excess fluoride. In Ethiopia, 8.5 million people are at risk of developing fluorosis from their water due to excessive fluoride uptake. Fluoride is a naturally occurring mineral that at elevated levels becomes a geogenic contaminant in groundwater. Because there is no effective medical treatment for the disease, the prevention of fluoride uptake is crucial.


Objectives
The main objective of this study was to compare the effectiveness of two behavior change strategies in promoting the consumption of safe water from a fluoride-removing community filter.


Activities
Step 1 & 2: Identify, measure and determine behavioral factors of fluoride free water use

  • Data gathering started with a baseline assessment in September 2010.
  • Differences between doers (100% use) and non-doers (less than 100% users) were compared in all behavioral factors.
  • Perceived monetary costs were significantly higher in non-doers than in doers, meaning that the non-doers rated the fluoride free water as 1.5 times more expensive.
  • No differences in perceived vulnerability were found, meaning that both groups assessed the risk of getting fluorosis in the same way.


Step 3: Select behavior change techniques (BCTs) and design behavior change strategies to enhance fluoride free water use.

  • The behavior change technique (BCT) inform about and assess costs and benefits was selected to target perceived costs. The corresponding behavior change strategy first stressed that a higher price for a product means that this product is of higher quality. Second, a consumption and cost calculation was conducted with the household to define the real additional costs of purchasing fluoride free water solely for drinking and cooking. In this way, the household received realistic estimates of how much filtered water was required and how much money the household would have to spend per week. This calculation demonstrated that the additional costs are quite small.
  • As a comparison intervention, a behavior change strategy was applied to raise risk awareness. It used the BCTs inform about and assess personal risk and arouse fear. First, the promoters asked for the names and ages of all children living in the household. Then, the promoter communicated individualized risk information for every child. The promoters showed pictures of children and adults with dental and skeletal fluorosis and indicated on a visualized scale how their risk could be reduced.


Step 4: Implement and evaluate behavior change strategies for fluoride free water use.

  • The behavior change strategies were evaluated through a before-after control trial.
  • The local non-governmental organization implemented the interventions in October 2010.
  • Half of the households received the cost persuasion strategy and the other half the risk-awareness strategy. 
  • A post-intervention survey was conducted in December 2010 to measure the behavioral factors and the consumption behavior.


Findings

  • As expected from the baseline data, the behavior change strategy targeting health risk awareness had no effects.
  • The cost persuasion strategy decreased the perceived costs by 50% and increased the consumption of fluoride-free water by 20%.


Conclusion
This project demonstrated that systematic behavior change strategies can change behavior by altering subjective perceptions of facts such as prices or walking distances even without changing objective circumstances.

Publications

Evidence-based tailoring of behavior-change campaigns: increasing fluoride-free water consumption in rural Ethiopia with persuasion

Two hundred million people worldwide are at risk of developing dental and skeletal fluorosis due to excessive fluoride uptake from their water. Since medical treatment of the disease is difficult and mostly ineffective, preventing fluoride uptake is crucial. In the Ethiopian Rift Valley, a fluoride-removal community filter was installed. Despite having access to a fluoride filter, the community used the filter sparingly. During a baseline assessment, 173 face-to-face interviews were conducted to identify psychological factors that influence fluoride-free water consumption. Based on the results, two behavior-change campaigns were implemented: a traditional information intervention targeting perceived vulnerability, and an evidence-based persuasion intervention regarding perceived costs. The interventions were tailored to household characteristics. The campaigns were evaluated with a survey and analyzed in terms of their effectiveness in changing behavior and targeted psychological factors. While the intervention targeting perceived vulnerability showed no desirable effects, cost persuasion decreased the perceived costs and increased the consumption of fluoride-free water. This showed that altering subjective perceptions can change behavior even without changing objective circumstances. Moreover, interventions are more effective if they are based on evidence and tailored to specific households.
Huber, A. C.; Tobias, R.; Mosler, H.-J. (2014) Evidence-based tailoring of behavior-change campaigns: increasing fluoride-free water consumption in rural Ethiopia with persuasion, Applied Psychology: Health and Well-Being, 6(1), 96-118, doi:10.1111/aphw.12018, Institutional Repository

Determining the differential preferences of users of two fluoride-free water options in rural Ethiopia

Aim. In the Ethiopian Rift Valley, 8.5 million people depend on water sources with excessive fluoride. In one rural village, a fluoride-removal community filter was implemented; a personalized reminder was distributed to change people's behavior and increase the usage of the in-village community filter. During this promotion phase, an alternative fluoride-removal option was installed in a neighboring village.
This study examines psychological factors that explain the differences in preference between the two options and their influence on the usage of the different sources. In addition, the effectiveness of the applied behavior change technique, a personalized reminder, on the use of the in-village community filter was analyzed.
Subject and methods. In a complete longitudinal survey, 180 households, with access to both mitigation options, were interviewed through structured, face-to-face interviews. Logistic regressions were carried out to reveal factors predicting the usage of the two mitigation options and the effect of the implemented behavior change intervention.
Results. The results showed that the better the taste, the lower the effort and the lower the costs for using the in-village community filter are perceived; in addition, the lower the perceived vulnerability to contract disease, the more the in-village community filter is used. Moreover, it was found that the personalized reminder also had a positive effect on the usage of the in-village mitigation option.
Conclusion. Based on the results, possible recommendations for practitioners and researchers are made to help plan and implement mitigation options.
Huber, A. C.; Mosler, H.-J. (2013) Determining the differential preferences of users of two fluoride-free water options in rural Ethiopia, Journal of Public Health (Berlin, Heidelberg), 21, 183-192, doi:10.1007/s10389-012-0537-4, Institutional Repository

Determinants of exclusive consumption of fluoride-free water: a cross-sectional household study in rural Ethiopia

Aim. The occurrence of high fluoride concentrations in the ground- and surface water all over the world leads to the risk of developing dental and skeletal fluorosis. In Ethiopia, 8 million people depend on water sources with excessive fluoride. In four project areas in the Ethiopian Rift Valley, fluoride removal household filters based on bone char media have been implemented. This study examines possible predictors of consuming filtered water derived from various behavior change theories.
Subject and methods. In a complete cross-sectional survey, 160 filter users were interviewed through structured face-to-face interviews. A logistic regression was carried out to reveal factors predicting consumption of filtered water.
Results. The results show that the consumption of fluoride-free water is mainly related to people's pride in offering filtered water to guests (status norm) and the feeling of being able to produce enough water with the filter (perceived behavioral control). Moreover, the study showed that the more filter users like the taste of filtered water and the more expensive they perceive the filter media, the more likely users will exclusively consume filtered water (attitudinal beliefs). Furthermore, perceiving the act of filling as a matter of habit (perceived habit) enhances filtered water consumption.
Conclusion. Based on the results, possible intervention strategies to change the influential psychological factors and, hence, increase the consumption of treated water can be designed.
Huber, A. C.; Bhend, S.; Mosler, H.-J. (2012) Determinants of exclusive consumption of fluoride-free water: a cross-sectional household study in rural Ethiopia, Journal of Public Health (Berlin, Heidelberg), 20(3), 269-278, doi:10.1007/s10389-011-0445-z, Institutional Repository

Determining behavioral factors for interventions to increase safe water consumption: a cross-sectional field study in rural Ethiopia

In developing countries, the lack of safe water options leads to many health risks. In the Ethiopian Rift Valley, most water sources are contaminated with an excess of fluoride. The consumption of fluoride-contaminated water leads to dental and skeletal fluorosis. The article presents an approach to designing community interventions based on evidence from quantitative data. After installing a community filter, a baseline study was conducted in 211 households to survey the acceptance and usage of the filter. To identify important psychological factors that lead to health behavior change, the Risk, Attitude, Norm, Ability, Self-regulation (RANAS) model was taken into account. Descriptive statistics were calculated for behavioral determinants, and their influence on consumption was analyzed with a linear regression. For every behavioral factor, an intervention potential (IP) was calculated. It was found that perceived distance, factual knowledge, commitment, and taste strongly influenced participants' consumption behavior and therefore should be tackled for interventions.
Huber, A. C.; Mosler, H.-J. (2013) Determining behavioral factors for interventions to increase safe water consumption: a cross-sectional field study in rural Ethiopia, International Journal of Environmental Health Research, 23(2), 96-107, doi:10.1080/09603123.2012.699032, Institutional Repository