Eighteen months ago, standing in a field in rural Cambodia, was the first time I seriously considered working in the water, sanitation, and hygiene (WASH) sector. I was in Cambodia to work on a nutrition project, and I was listening to a young mother explain how she was struggling to help her daughter gain weight. As soon as the little girl seemed to be making progress, she would get sick with diarrhea, and all progress would be lost. No matter how good our nutrition program was, if we could not keep the little girl healthy, nothing else we did would matter. Statistically, it was most likely that the little girl’s illnesses were caused by lack of access to clean water, proper sanitation, and good hygiene—88 percent of cases of diarrheal diseases are. But, I still did not know what we could do. Our program had some components encouraging hand washing behaviors and latrine use, but our data showed that households adopted these behaviors briefly and then reverted back to their old habits.
What I did not know then is that I had inadvertently stumbled upon one of the biggest questions the WASH sector faces: How do we create sustainable behavior change?
Behavior change is difficult. We are all stuck in our ways, and adopting new actions can be tricky. For example, many people have trouble remembering to floss. I know I do! Brushing my teeth is a habit, while flossing is an intention-driven action—it’s triggered by a host of motivations: social norms, attitudes, rational benefits, and (good) intentions. While habit-driven actions are easy and automatic, intention-driven actions require conscious effort. Establishing flossing as a habit, instead of as an intention-driven action, is the key. This is the science of habit, and it may be fundamental to creating sustainable behavior change.
In many parts of the world such as Cambodia, hand washing and latrine use are not common behaviors due to cultural norms and lack of access to appropriate facilities. When first introduced, these behaviors are like flossing—they require conscious effort. However, if we can transform these actions into habits, they are far more likely to “stick.”
Since joining Plan in May, I have been working on the Cambodia Rural Hygiene and Sanitation Improvement Program (CR-SHIP), which is doing just that—creating sustainable behavior change around sanitation and hygiene practices. CR-SHIP first triggers demand for sanitation and hygiene by raising awareness about the dangers of open defecation and poor hygiene. The goal of these initial activities is to trigger feelings of disgust, so that community members are motivated to improve their situations. The program then supports communities as they build their own latrines and hygiene facilities, and educates them about best practices. These activities lead to the improvement of the infrastructure, and widespread behavior change; however, Plan doesn’t stop there. The goal is not just to trigger behavior change, but to make it sustainable. To do that, we have to make sure that these new behaviors become habits.
Recently, I participated in a Science of Habit and Hand washing Webinar by David Neal, Ph.D. that described several principles that may help turn behaviors into habit. As I listened to the talk, I realized that even though we use different words, CR-SHIP aligns well with many of these steps. Dr. Neal’s steps include:
1. Supporting environment: ensure that the critical infrastructure and products are immediately available so that the behavior can happen consistently and effortlessly.
Through sanitation marketing and other activities that support the supply side of sanitation and hygiene, Plan ensures that communities have easy and consistent access to the facilities and products necessary to develop and maintain healthy WASH habits.
2. Leverage the context: take advantage of context changes during which time people are more open to creating new habits, or piggyback new behaviors onto existing behaviors.
As soon as the sanitation behavior change triggering process begins, Plan works to support communities to improve their situation, change their behaviors, and take advantage of the drive of improved hygiene.
3. Eliminate friction: eliminate choice, steps, and perceived effort for new behaviors.
Plan works with communities to develop the easiest methods of sanitation and hygiene, and to remove barriers to good behavior whenever possible.
4. Intervention through doing: make sure that the intervention has tactics that involve people actually doing the behavior so that a procedural memory is formed.
Plan’s intervention activities involve active participation and engagement from the communities. For example, during hygiene lessons in local schools children physically practice washing their hands instead of just learning the steps in a classroom.
5. Conscious storytelling: once the habit is formed, encourage people to infuse the action with personal significance.
Plan uses behavior change communication campaigns to remind communities about the importance of good hygiene. For example, images remind caregivers that if they feed their children with dirty hands, they may be making their child sick. As a result, the actions gain additional significance and the children themselves become a prompt for hygiene actions.
The WASH sector is still learning what works and what does not work to create sustainable and long-term behavior change, and Plan is helping to solidify the path with large-scale interventions like CR-SHIP. Plan is working hard to transform behavior change into sustainable habits, which means that thousands of girls and boys just like the one who inspired my interest in WASH now have a much better chance of growing up healthy. To many this work may seem uninspiring—I am frequently asked why I choose to spend my days thinking about sanitation—but, as I learned 18 months ago, sometimes it’s necessary to focus on the basics to make real progress.