WASHplus Participates in Panel on Behavior Change to Facilitate Clean Cooking

On Tuesday April 21, the USAID Translating Research into Action Project (TRAction) held a panel discussion at the National Press Club in Washington, DC to discuss behavior change strategies for clean cooking. The event highlighted lessons from a recently published special issue of the Journal of Health Communication, Advancing Communication and Behavior Change Strategies for Cleaner Cooking.

Household air pollution (HAP), caused by the indoor burning of wood, crop residue, and other solid fuels, causes millions of premature deaths every year. Correct and consistent use of clean cooking technologies and fuels can reduce household air pollution, but adoption requires significant changes to existing cooking behaviors. The special issue of the Journal of Health Communication presents findings on methods to promote the adoption of clean cooking technologies and fuels, and aims to advance our understanding of behavior change related to technology, the enabling environment, and demand creation.

Julia Rosenbaum, USAID/WASHplus Project Deputy Director, and Elisa Derby, the WASHplus Indoor Air Pollution Specialist, co-authored an article in the Journal of Health Communication titled “Behavior Change Communication: A Key Ingredient for Advancing Clean Cooking.” On April 21, Julia joined several guess editors and authors of the special issue to discuss lessons learned and next steps for behavior change in the clean cooking sector. This panel discussion on “Behavior Change for Clean Cooking: Current Knowledge and Next Steps” featured Jay Graham from George Washington University, Sumi Mehta from the Global Alliance for Clean Cookstoves, Nigel Bruce from the University of Liverpool, Anita Shankar from Johns Hopkins University, and Jessica Lewis from Duke University.

During her presentation, Julia emphasized that behavior change is possible by showing examples from the water and sanitation, HIV, and nutrition sectors. She highlighted the need for comprehensive strategies including but not limited to, communication tactics, researching a range of actors on the values chain, and systematically understanding what motivates a particular target group to perform a behavior. One cross cutting approach to changing clean cooking behaviors is to identify small doable actions that are feasible and can have a significant health impact.

View a recording of an interview with Julia below. See her presentation: “Behavior Change Approaches to Facilitate Clean Cooking and Reduced Household Air Pollution” (download presentation slides).

Behavioral Challenges and Potential Solutions to Reach Universal Sanitation Coverage


By Orlando Hernandez, USAID/WASHplus Project and Senior Monitoring and Evaluation Advisor, Global Health, Population and Nutrition (GHPN), FHI 360.

The comments below are from Dr. Hernandez’s participation at the World Water Forum 2015 and then posted to the Sanitation and Water for All website.

Behavior change specialists rely on frameworks to dissect a problem and define a strategy to address it. The Water Improvement Framework (WIF), previously named the Hygiene Improvement Framework (HIF) developed in connection to USAID WASH projects some 15 years ago, is one such framework. Given its openness and comprehensiveness, the WIF has stood the test of time. Other donors and implementation agencies are thinking along the same lines as there are other similar frameworks developed by WSP, SVN, the London School of Hygiene and Tropical Medicine, among others.

The WIF is a three-legged stool which brings together: 1) supply, 2) demand, and 3) the enabling environment. It suggests that behavior change (BC) strategies are more than mere promotion, channels and messages. They bring a human dimension to the WASH sector, and when based on the WIF’s the three elements, it guides us to design, implement and evaluate WASH activities. orlando2

Behavior change frameworks require us to segment our audiences as social groups involved in development are not monolithic. One obvious breakdown in sanitation is a split between urban, peri-urban and rural dwellers. The needs, preferences, sanitation practices and certainly resources of urban, peri-urban and rural populations may be different. With growing urbanization throughout the developing world, coverage in peri-urban areas represent a challenge, especially when we think of tenants living in crowded quarters with no services.

Addressing appropriate sanitation practices in peri-urban areas will require appropriate sanitation options that would allow peri-urban residents to dispose safely of human feces. There are recent innovations which make us think about the importance of ‘human centered design’ for identifying effective supplies and products required to carry out an action. A first step in behavior change is to have the right enabling products as well as the needed access to such a product that a targeted population needs to have in order for a promoted practice to occur.

Sanivation in Kenya, for example, has developed the Blue Box. This is a container-based toilet that is placed in any room in someone’s home and serviced regularly by Sanivation’s Toilet Service Representatives. Sanivation then transforms the collected material in high-performing charcoal briquettes, which are resold on the market. Blue Box clients get a toilet and services to remove fecal matter from their homes for US$7/month.

This approach is based on research suggesting that 50% of Kenyans were planning to invest in improved sanitation, but that many of those living in peri-urban settings may be paid monthly salaries and could have no savings to construct a toilet, may have no space to build a latrine, or be moving away to another location in the near future and do not want to make permanent home sanitation improvements that would be forced to leave if and when they do move. The Blue Box toilet relies on a subscription service, has come to be perceived as a status symbol, and has a marketing strategy that relies heavily on word of mouth. There are other similar options to – dwellers: loowatt in Madagascar, Sanergy also in Kenya, etc.

We are probably all too familiar with the experience of easy latrine in Cambodia designed also using human centered design principles by iDE to come up with a toilet that responded to sanitation needs and preferences of rural residents. Three principles guided the design of these toilets as products that will be purchased by consumers to satisfy their needs. These principles can be referred to as those that meet the three A’s of a marketable product: aspirational, accessible and affordable. Cambodia was a country with 20% rural sanitation coverage when the work of IDE started.

Formative research conducted identified the characteristics of an attractive rural sanitation option. These rural consumers were interested in having a pour flush toilet with an off-set pit and a concrete superstructure that may constructed in due time once resources become available. Such a product was baptized as the easy latrine and ended up being the appropriate technological option for rural Cambodian households. Project implementers in Cambodia resolved production and supply chain issues and more quickly than expected sales and coverage increased considerably.

Universal coverage requires eliminating open defecation as a first step, and such a goal will not be achieved if open defecation is not eradicated in large countries, including India. The Government of India has a program that subsidizes latrines so households have no economic barriers to overcome in order to have latrines at home. Subsidies resolve an important barrier helping to increase access. However, access is a necessary but not a sufficient condition for use of an installed technology to use.

Access does not mean use or correct use. The Research Institute of Compassionate Economics (RICE) at Emory University, with Gates funding, has clearly demonstrated the multiple motivational barriers have to be overcome especially in Northeast India to get people that may have latrines constructed at home at the government’ s expense to accept having them installed, and also in using them.

The research conducted by RICE at Emory has demonstrated that family members in rural settings have morning walks, leaving home to breathe clean air in the woods as they wake up, and that at the end of their walk they defecate before returning home. In addition to enjoying a morning walk, there is a preference to leave their fecal matter away from home. We will be challenged to bring human centered design to address not only the specifications of on-site sanitation, but possible the characteristics of off-site sanitation.

Perhaps we need to think about the possibility of setting up public toilets in current open defecation sites. I know that off-site defecation may not be counted as part of meeting universal coverage, but we may forced to expand our definitions to take into account special circumstances affecting millions of people.

Rural sanitation offers other challenges that we should be prepared to address, even we have detected the appropriate technology as was the case in Cambodia. CLTS has been used in many countries, supported by donors and adopted by many public and private implementing agencies. However, it is an approach that is implemented in different phases including pre-triggering, triggering, adoption, sanitation facilities construction and certification.

It is certainly an approach that requires considerable institutional implementation capacity in addition to involvement of central and local government officials, community mobilizers, masons, lenders, etc. It is also an approach that moves at its own pace, village by village. The presence of multiple villages will require multiple implementation teams. I should add that participatory approaches are likely to be more effective than top down approaches that offer cookie cutter solutions.

A review of rural sanitation programs implemented in the past few years in Latin America has demonstrated that even when institutional capacity is in place, solutions exclusively from the desk of technicians that do not incorporate community members to the process of change may backfire.

Now, let me turn to a related topics: consistent use over time for all family members. Implementers of CLTS programs in multiple countries over time are beginning to generate data that helps to see what even when there is the right technology and the right institutional support to increase coverage, we may be confronted with the problem of recidivism.

Some of these implementing agencies are indicating that in some instances up to 30% of households with sanitation coverage may come back to open defecation . So, one challenge is how to make sure that family members continue to use available sanitation over the long run. We will also be concerned with the fact that the feces of all family members should be disposed of hygienically.

And in this regard, the disposal of child feces will emerge as a larger challenge than we think. Families that have access to sanitation facilities should use them to dispose of child feces. Some studies in which I have been involved open the door suggest that this is not necessarily done. If there is recidivism among adult family members, there may not be consistent hygienic disposal of the feces of younger family members, even when latrines are available.

Habit formation concepts are beginning to offer a new way of thinking regarding consistent use of a practice over time. They suggest that to instill sticky habits we must help construct routines that are driven by external cues and are repeated over time automatically.

Settings must be stable so that external cues remain constant. In addition, habit formation principles suggest that we must try to piggyback practices onto existing habits. Studying what sequence of events occur when we engage in cleaning up a child may help identify how the appropriate disposal of these feces can be integrated to such a sequence.

Universal coverage often means on-site sanitation for households. However, there is a homeless population of over a billion individuals in the world, data that was recently shared with be by a colleague from Bangladesh attending this forum.

But if the current proposal stands, the Sustainable Development Goals will define universal sanitation including both households and institutional settings, namely schools and health facilities. The WIF can be of use when deciding how to tackle behavioral issues in school populations and clients and staff at health facilities.

The health and nutrition and nutrition benefits of WASH investments may not be reached if we ignore handwashing with soap at critical junctures, before handling food and after potential contact with fecal matter. Future handwashing promotion programs targeting households should focus on having households set up permanent handwashing stations near toilets or places where food is handled, and ensuring that these stations are duly supplied with soap and water, if no tap are available.

The challenges presented by handwashing promotion are large, but it has been done for a long time now and we have different ways of tackling them. That, nevertheless, is a different discussion that we can pursue at another time.

I hope that these remarks help us have an eagle’s view at the behavior change challenges ahead of us and some potential ways to address them. We must be open to technological innovations but also to innovative behavior change approaches and new ways of tracking our achievements. I also hope that it stimulates your thinking and generates discussion.

WASHplus presents at CIES 2015

Lets Talk About It

WASHplus staff participated in four events at the 2015 Comparative and International Education Society (CIES) Conference.  From the WASHplus SPLASH Project in Zambia, Chief of Party Justin Lupele spoke on a panel hosted by the USAID/Zambia education projects on “Why WASH Is an Essential Element of Quality Education.” A poster on the same theme was also displayed. Sarah Fry, WASHplus’ Senior Technical Advisor on WASH in Schools, made a presentation titled “Let’s Talk About It: Safe and Equitable Learning Environments in Zambia,” which focused on SPLASH’s Menstrual Hygiene Management (MHM) advocacy and activities. Renuka Bery, WASHplus Technical Advisor on WASH & Nutrition Integration, facilitated a workshop on “Clean, Fed & Nurtured,”  along with Carol da Silva from FHI 360, and Monica Woldt from the USAID FANTA Project. Participants formed groups to conduct an activity around Identification of Risks and Opportunities in WASH, Nutrition, and Early Childhood Development in the Home and Surrounding Community. The presentation that accompanied the workshop can be viewed here.

Celebrating World Health Day: Why Food Hygiene Matters

You are what you eat

It is estimated that 2 million deaths occur every year from contaminated food or drinking water. Diarrheal disease alone kills an estimated 1.5 million children annually, and most of these cases are attributed to contaminated food or drinking water, according to the World Health Organization (WHO). 

In Uganda, the WASHplus project worked closely with USAID implementing partners including Community Connector, SPRING, STAR-SW, FANTA, and others to integrate WASH and aspects of food hygiene, among other interventions, into HIV care and support. WASHplus developed a series of job aids to support outreach workers and clinical counselors to integrate WASH into their home-based and clinical practice. The job aids are available in English, and two local languages, Rukiga and Rufumbira. Also, notable in WASHplus’s work in Uganda is the application of the small doable action approach to food hygiene to address local challenges of keeping food safe.

Resources developed by WASHplus are provided below.

Integrating Safe Water, Sanitation, and Hygiene into Infant and Child Nutrition Programmes. A Training Resource Pack for Uganda, 2014.

Integrating Safe Water, Sanitation, and Hygiene into Infant and Child Nutrition Programmmes

In Uganda, the WASHplus project is integrating WASH into to Nutrition and Feed the Future Programming. Integrating WASH into nutrition focuses on the importance of improving household sanitation and nutritional needs in a child’s first 1,000 days. By building capacity of implementing partners and district focal and community resource personnel, WASHplus facilitated the integration of WASH into clinical nutrition assessment, home visits with householders of small children and families affected by HIV, and through community mobilization campaigns. For example, Community Connector now not only includes WASH as part of the model homes in its 1,000 days campaign, the project included WASH in its community drama initiatives, radio talk show, behavior change communication materials, and field day exhibition, which emphasized the integration of nutrition, agriculture, income, and WASH. Integrating WASH into the District Nutrition Coordination Committees further emphasized the importance of WASH and nutrition integration during the budgeting process, implementation, and supervision of district efforts to fight undernutrition.

Small Doable Actions for Improving Household Water, Sanitation, and Hygiene Practices. Job Aids for Village Health Teams, Peer Educators, and their Supervisors (English, RufumbiraRukiga), 2104.

Small Doable Actions for Improving Household Water, Sanitation, and Hygiene Practices -Job Aids for Village Health Teams_Peer Educators_Supervisors

Small Doable Actions for keeping food safe

Working with SPRING, WASHplus created the first-ever job aids promoting small doable actions for food hygiene, based on the World Health Organization’s “Five Keys to Safer Food.” The job aids address issues of food safety during preparation, serving, and related to storage. This initiative directly addressed the contribution of poor food handling in spreading contamination that leads to diarrhea. Other job aids highlight safe disposal of infant and animal/poultry feces, which may be significant contributors of undernutrition and inhibitors of growth according to a growing evidence base. Feces from these sources find their way to a child’s mouth through food or water contamination or through direct ingestion, causing diarrhea, enteropathy, and contributing to the excessive growth stunting documented in the region.

Additional WASHplus Resources

You Are What You Eat: Why Food Hygiene Matters for Child Growth. Julia Rosenbaum, FHI 360/Deputy Director of the USAID funded WASHplus Project, and Merri Weinger, USAID/Bureau for Global Health/Environmental Health Team leader. A presentation at the USAID Mini-University, March 2015.

Why WASH Matters for Improved Child Health, Nutrition & Growth: A Knowledge Sharing Event. Julia Rosenbaum, FHI 360/Deputy Director of the USAID funded WASHplus Project, June 2014.

Hygiene Intervention Reduces Contamination of Weaning Food in Bangladesh, Islam et. al. Tropical Medicine and International Health, Volume 18, no 3, pages 250–258, March 2013.

World Health Day is April 7!

five keys to safer food (WHO)

On World Health Day, the World Health Organization (WHO) is highlighting the challenges and opportunities associated with food safety under the slogan “From farm to plate, make food safe.” The WHO has developed simple global health messages called the The Five Keys to Safer Food to explain the basic principles of food safety (see below) and launched a global social media campaign, asking people to tweet why food safety is important to the hashtag #SafeFood.

Join the World Health Day celebration! Send a strong message about food safety—what it is, and why it is important to you!

Additional Resources:

10 Facts on Food Safety, World Health Organization, 2015.

Fact Sheet on Food Safety, World Health Organization, 2015.

World Health Day 2015: Toolkit, World Health Organization, 2015.

Let’s Talk About It! Safe and Equitable Learning Environments in Zambia


The learning environment is often the biggest barrier to girls staying in school. The environment that best addresses girls’ needs in school includes:

  • Gender-friendly sanitation facilities at 50:1 ratio
  • Access to MHM products and materials
  • Teachers trained to talk about menstruation and provide support to girls
  • Boys and male teachers involvement in MHM support
  • MHM related activities (learning games, exhibitions etc.)

LEARN MORE: http://www.washplus.org/sites/default/files/fry-cies2015.pdf

Expanding WASH Coverage in Bangladesh

bangladesh water pump

WASHplus mounted intensive, accelerated efforts in a new expansion subdistrict in the Khulna District in response to USAID interests in water technology innovations. It has also been working with a new local NGO partner, Shushilan, to begin installation of rainwater catchment and pond sand filtration systems. In the original four subdistricts, WASHplus continues to construct water points and latrines as well as train community members on operations and maintenance for the new WASH (water, sanitation, and hygiene) facilities.

The numbers tell the story: WASHplus is well placed to reach, and even surpass, its proposed targets for open defecation free (ODF) communities, number of new water points and latrines, and water and sanitation beneficiaries. This is happening despite the fact that flooding delayed the documentation of ODF communities, and storms damaged a number of new latrines. Fortunately, new construction standards meant that the latrines sustained primarily superficial damage, and households were resilient enough to make repairs. Also, WASHplus has surpassed the target for number of people gaining access to sanitation facilities by 691 (100.78 percent), and is 88 percent of the way toward the three-year beneficiary target for water access.