Department Environmental Social Sciences

Access to water, sanitation and hygiene is fundamental for the prevention of diarrhea. This project aims at improving access to safe water and sanitation for families in rural Burundi. In collaboration with the Deutsche Gesellschaft für internationale Zusammenarbeit (GIZ) GmbH we developed behavior change interventions. A water intervention focused on safe water handling and stocking methods and a sanitation intervention focused on improving the latrine and regular latrine cleaning. Local health volunteers encouraged behavior change in neighborhood meetings by targeting psychological factors, namely disgust, perceptions of price, positive emotions towards hygiene and by a personal commitment. First results show that latrine cleanliness and quality as well as water handling improved. Neighborhood meetings were more successful in reaching the population than a public theater play.

Context
Lack of access to safe water, sanitation and hygiene is still one of the leading causes for child mortality in developing countries. Burundi is rated as one of the 10 countries with the lowest human development index worldwide and it has a high mortality rate amongst under-fives of 142 per 1000 births. Water is often contaminated on the way from the source until consumption through improper handling. Though most rural families do have their own latrines their quality is still unsafe. They are built very rudimentary and often poorly maintained and dirty. With behavior change interventions access to safe water and sanitation could be improved.

Objectives
The overall goal of this project is to promote safe handling and stocking of water and improving sanitation in rural Burundi. Additionally, different promotion activities, which could be used at scale were tested. Specific goals were:

• Improving water stocking and handling by promoting a new water stocking container and regular cleaning of water vessels.
• Improving access to safe sanitation by promoting improvements of the latrine and regular cleaning.
• Determining which promotion activity would be more successful: neighborhood meetings or a public theater play.

Activities
Step 1 & 2: Identify, measure, and determine behavioral factors

• In 2012 in a baseline study, 761 households were interviewed regarding their current behaviors and attitudes towards water, sanitation and hygiene.
• Based on the results we decided together with the GIZ to implement interventions to improve access to safe water and to improve existing latrines.
• We identified disgust, perceptions of price, positive emotions and commitment strength as most influencing behavioral factors.

Step 3: Select behavior change techniques (BCTs) and design behavior change strategies

• We selected three BCTs.
• Describe feelings about performing and about consequences of the behavior to target disgust and positive emotions. Promoters emphasized the satisfaction and pride one can feel for example when owning a well built and clean latrine and on the other hand the disgust, that can be evoked for example when drinking from a dirty glass.
• Inform about and assess costs and benefits to target perceived costs. Promoters discussed about the cost of improving the latrine by comparing it to the costs of a cell phone. Thereby they focused on strategies participants knew already to collect enough money to buy a cell phone or a latrine.
• Prompt to agree on a behavioral contract to strengthen personal commitment. Promoters invited participants to personally commit to change their behavior (e.g. clean water vessels regularly) and gave them a sticker as a sign for their commitment.

Step 4: Implement and evaluate behavior change strategies

• BCTs either were delivered through neighborhood meetings guided by local health volunteers or through a public community meeting with a theater play.
• In late 2014, an evaluation survey took place.
• Change in behavior and behavioral factors was evaluated through before-after and group comparisons.

Findings
First results show that:

• The interventions changed behavioral factors like positive emotions and disgust.
• The water intervention motivated people to clean their water vessels more often compared to the control group. However, the promotion of a new stocking container was a failure due the price, which was perceived to be too high.
• The quality of latrines and their cleanliness improved in the groups, which had neighborhood meetings.
• The theater play could not reach enough people and had no effects.

Conclusion
Behavioral change strategies can change behavior by targeting behavior factors. However, not all promotion activities can be used at scale. The reach of a theater intervention was simply too small to trigger behavior change whereas local health volunteers were able to reach the population through neighborhood meetings.