There are multiple dimensions to consider if hygiene programmes are to be sustainable: the sustainability of behaviour, infrastructure, services and systems. Each of these components reinforce each other.
Image: Hygiene Hub
1. Sustaining behaviour change: To increase and sustain hygiene behaviours, such as handwashing or mask-wearing, we need to consider whether people are likely to continue to practice the behaviours after active promotion comes to an end. Two systematic reviews of hygiene-related behaviour change address sustainability, and both conclude that evidence about the sustainability of behaviour change programmes is limited (Study 1, Study 2). One of the reviews explored factors that influence sustained WASH behaviours, but it was unable to draw conclusive findings. However, the factors outlined below are likely to be important for the adoption of handwashing behaviours during the programme period and sustaining them after the programme ends:
Knowledge alone doesn’t enable sustainable behaviour change – Interventions employing one-way communication with the intention of increasing knowledge or skills surrounding hygiene were not found to have any effect on sanitation outcomes nor lead to any sustained change in handwashing behaviour.
Design programmes based on theory and address determinants of behaviour – Interventions based on theory are more likely to increase handwashing behaviour change. Behaviour change interventions which combine psychosocial theory with an enabling environment are more likely to increase handwashing behaviour change and facilitate handwashing station maintenance. Addressing a range of determinants of handwashing, rather than just a few factors, will also likely lead to sustained changes.
Promote community ownership, leadership and support– Psychological and community-level resources (e.g. social support from the family and community) can help enable behaviours. Community engagement in running the program, from planning to design, implementation and oversight, will likely increase ownership. Some examples of community-based approaches for WASH interventions include Community Led Total Sanitation (CLTS) and Participatory Rural Appraisal (PRA) approaches which have a sanitation component. To make it possible for behaviour change to be sustained, a sufficient ‘dose’ of the intervention needs to be achieved. Achieving sufficient ‘dose’ requires programmes to reach and engage their target populations enough times to achieve an effect, therefore requiring community engagement over time. It also requires programmes to consider the best ways of reaching all members of a society. Utilising multiple delivery channels can also help in achieving a sufficient ‘dose’ and enabling programmes to be effective at changing behaviour in the short and longer-term.
Work towards longer-term habit formation – For a behaviour to become a habit it needs to move from something that we consciously think about to something that is semi or fully automatic and done in response to familiar cues. Creating an enabling physical and social environment can therefore contribute to habit formation. Including signs or nudges about when to practice the behaviour and mandatory handwashing or mask-wearing in institutional settings can facilitate behaviour change. A habit-enabling environment normally requires: a) a stable, unchanging setting where the behaviour takes place, b) continued access to the necessary products required to perform the behaviour, c) an existing routine or series of actions into which the new, desired behaviour can fit into, and d) adjusted perceptions of social norms related to these behaviours. Visual cues can remind people to practice hygiene behaviours. Legal and regulatory interventions may promote lasting behaviour change in the interest of public health. Laws limiting the sales of tobacco products to minors, restricting smoking in public places, and mandating the wearing of a seatbelt while driving are some examples of how regulations can influence public health outcomes and lead to long-term changes of behaviour.
Address motivators for behaviour – Motivators such as enjoyment and satisfaction from handwashing, self-determination, and identity can contribute to sustained behaviours. People may experience sensory rewards from practicing hygiene behaviours, such as having pleasant smelling hands after washing them with soap. The SuperAmma campaign to promote handwashing behaviour in Southern India is an example of how motivators can be leveraged to change behaviour, such as a mother’s motivation to nurture her child and ensure their future success. Another study conducted in Nepal, Pakistan and the Philippines explored other emotional motivations for handwashing behaviour, including shame and respect.
Leverage local norms – It can take time to change social norms. However, it can be relatively easy to change normative perceptions (i.e. people’s perceptions of what people do or how others should behave) and this in turn can contribute to behavioural change. Norm-based messaging can draw attention to the behaviour of others and make people more aware that others pay attention to their behaviour. There is evidence that individuals are more likely to practice handwashing behaviours when they are being observed or are in the presence of others. However, handwashing may often take place in settings that are private or hard for others to observe behaviour (e.g. bathrooms). To overcome this, other mechanisms within programmes can draw attention to normative behaviours, such as showing people washing their hands and adopting prevention behaviours on social media or television. One study conducted in Ethiopia found that people with strong injunctive norms (behaviours that are approved or disapproved by others) and descriptive norms (behaviours that are practiced by others) were more likely to practice handwashing behaviour, and suggested that an intervention requiring a public-commitment to wash hands would help promote both types of norms and likely lead to increased handwashing.
The table below is based on a systematic review of handwashing and sanitation behaviour change interventions and gives an overview of how uptake, adherence and sustainability are likely to vary between interventions. Community based approaches and interventions based in theory are more likely to result in uptake and adherence, but still do not have enough evidence to support sustainability.
2. Sustainable enabling technology: Sustainability may not be possible if the behaviour is not convenient and easy to practice. Having infrastructure in place is key for ensuring the behaviour can be convenient, and therefore having an ongoing supply of products to maintain the infrastructure is essential (Study 1, Study 2). If programmes involve the provision of infrastructure or encourage communities to invest in infrastructure that enables behaviours (such as handwashing stations in homes, health facilities and public places), then it is important to consider how to put in place a system for maintaining this technology. This resource explains how the design of handwashing facilities can have an impact on handwashing behaviour. Desirable facilities are more likely to be utilised and maintained. During COVID-19 there has been a dramatic scale-up in the number of organisations investing in handwashing facilities in public places. WaterAid and the Sanitation Learning Hub have developed guidance on public handwashing facilities, and both cover important steps for enabling the ongoing operation and maintenance of these facilities. The sustainability of handwashing facilities needs to be considered from the outset. This should include involving the target population in the design of the facilities to ensure that they are acceptable, desirable and accessible for everyone to use. Sustainability can also be improved by constructing the facilities from materials that are durable, or which can be replaced easily and locally. They also recommend establishing an operation and maintenance plan with local institutions or communities and set out roles and responsibilities in relation to who should fund, purchase and refill the soap and water, who should clean the facility (and how it should be cleaned), and who should fix the facility if it is broken.
3. Building sustainable services: Some behaviours, like handwashing with soap, require infrastructure, products and access to services such as a regular water supply. The pandemic has drawn attention to long-standing global inequities in water access and to the importance of promoting inclusive services which provide water for all sub-groups of the populations (e.g. including those in rural locations, who are displaced and living within camps or people with disabilities). During the pandemic, governments and water service providers in many regions adapted their services and put in place mechanisms to enable populations to access more water or make it more affordable. For example, some governments in Africa drilled additional boreholes or organised short-term, water trucking services to water scarce communities. Other countries have waived water bills or provided water subsidies during the pandemic. As COVID-19 response funding reduces or response initiatives wind down, it is important that we don’t see a return to the status quo. A coordinated systems approach will create lasting change. This may require actors to develop a better understanding of water vulnerabilities by mapping access and the regularity of water supply. Such information can be a vital tool for advocacy and the prioritisation of longer-term investment in water infrastructure. Secondly, it will require governments, community organisations, donors, NGOs and consumers to develop strategies and plans which actively work towards more sustainable water services. UNICEF’s Framework for Programming for Sustainability in Water Services outlines a pathway for actors to achieve this.
4. Building sustainable systems: During outbreaks, coordination between non-government response actors and governments is often suboptimal. However, past outbreaks have demonstrated that as the response progresses into a more protracted phase, these coordination systems also mature. Transitioning from the acute phase of the COVID-19 pandemic requires coordination of mechanisms, strategies and policies and even individual programmes are reviewed and adapted with sustainability and system-level changes in mind. COVID-19 created a ‘shock’ to international health systems and at the same time has created an opportunity to build more resilient health systems in the long term. Resilient health systems would be able to identify, prevent or mitigate the spread of future outbreaks and reduce the impact of chronic health challenges like diarrhoeal disease. This article explains that responding to such a health system ‘shock’ requires improvements to health information systems, funding/financing mechanisms and the health workforce. Realising these changes requires advocacy to highlight gaps in the health system and develop policies and strategies to address them. Many COVID-19 programmes have also been ‘vertical’, meaning that they only prevent or treat COVID-19. At this point in the pandemic, it is key that programming shifts to be more ‘horizontal’, meaning that COVID-19 prevention activities are integrated within other ongoing aspects of health programming. This is more likely to lead to health-system strengthening and allows for the continued provision of health and hygiene services without interruption or any decrease in quality.
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