Behavior Change - Environmental Health at USAID

1 Environmental Health ProjectBehaviorChangeLessons LearnedEHP Goal: Increase thecapacity of local NGOsand communities toidentify high-risk envi-ronmental Health -relatedbehaviors and to designand implement behav-ioral Change programs toachieve a Health recently, Behavior Change hasnot been given the importance it is duein Environmental Health programs. Forexample, water and sanitationprograms, even those with Health goals,have all too frequently focused mainlyon provision of hardware pumps,pipes, latrines and the most commonindicator for such programs has beenthe number of people with , research has shown thatit is correct use of water and sanitationfacilities that yields the greatest healthimpact.

2 Access alone may bring little orno Health impact. For example, manypeople have access to a latrine but donot use it for practical and culturalreasons that were not taken intoconsideration when the latrine was greatest Health impact, a number ofbehaviors must be adopted regardinglatrine use: all members of the family,including children, must use the latrineat all times, they must wash their handsafter latrine use, and the latrine must bekept clean and functioning. In addition,the feces of children too young to use alatrine must be disposedof its efforts to prevent keychildhood diseases, the EnvironmentalHealth Project (EHP) advocates theconcept of Behavior first.

3 In otherwords, first find out what behaviors areassociated with disease transmission inBehavior Change to preventenvironmentally related diseases takesplace in both the public or communitydomain and the private or domesticdomain. Private-domain behaviors areactions that individuals or familiesthemselves structure and organize, suchas washing hands; community behaviorsare collective actions that call fororganizing people to work together,such as maintaining a community pumpor keeping a common area clean. Tofacilitate both individual and collectiveaction, national, regional, and/or localgovernment decision makers may needto provide resources and number of EHP activities haveachieved Behavior Change results.

4 Thefollowing representative list shows thewide range of behaviors targeted: Montego Bay, Jamaica: properexcreta disposal; The Cono Norte area of GreaterLima, Peru: collection and properdisposal of solid waste; The Santa Cruz area of Bolivia:water storage/handling and excretadisposal; Two secondary cities in Tunisia:maintenance of common areas inneighborhoods ( , improvingthe target area and then identifystrategies for bringing about the neededchanges. The strategies may include but are not limited to introduction ofnew technologies.)

5 Communication,training, policy Change , and communityorganization are also strategies forbehavior Change . Technology is not thesolution; it is part of the Change is part of a series of leaflets produced in 1999 by the Environmental Health Project (EHP) to document lessons learned ineight results areas. EHP is a project of USAID s Office of Health and Nutrition, Bureau for Global Programs, Field Support and Research. Thisseries was produced by EHP under the management of Camp Dresser & McKee International Inc.

6 With funds from USAID (Contract No. HRN-C-00-93-00036-11). Other leaflets cover Diarrhea Prevention, Malaria Prevention, Environmental Sanitation Policies, Services for the UrbanPoor, community Involvement, Risk Assessment, and Institutional 1999 UNICEP/90-0008/Ellen TolmieEnvironmental Health Projecttrash collection, drainage,maintaining latrines, etc.); Cit Soleil, Haiti: communitymaintenance and protection of thewater distribution network; Zlatna, Romania: protectingchildren from exposure toenvironmental lead; and Eastern Province in Zambia: usinginsecticide-treated all cases, technologies were involved,from simple ones, such as water storagecontainers, to more complex, such aswater system construction.

7 Thetechnologies were one element inmaking the new behaviors substantial results that can beachieved from behavioral Change effortsare illustrated in post-projectevaluations. For example, in Ecuadorianprovinces where high rates of cholerapersisted despite governmentinformation campaigns, EHP workedfrom 1994 to 1995 with USAID /Quitoand the Ministry of Health to identifybehaviors and beliefs that increase therisk of cholera. Regional andcommunity Health teams were formedand trained to analyze local beliefs andbehaviors in indigenous communities,and, in conjunction with communitymembers, to design suitableinterventions.

8 The 1996 final evaluationfound a 34% increase in the number offamilies treating their drinking water, a94% increase in those protectingdrinking water, and a 27% increase inthose washing their hands afterdefecation, compared with baselineinformation to mention just a fewresults. The number of cholera casesdropped dramatically in the projectarea, compared with contiguous the Santa Cruz area of Bolivia,where previous USAID funding ofwater and sanitation infrastructure failedto bring about the anticipatedreductions in child diarrheal disease, theUSAID mission and EHP mobilizedlocal NGO groups and the ChildHealth Unit of the Ministry of Healthto take a community -based approach toprevention of diarrheal disease.

9 Baselinehousehold morbidity data revealed thatthe actual burden of child diarrhealdisease was an order of magnitudegreater than what clinic data , child diarrheal diseaseprevalence was highly correlated withpoor hygiene behaviors and lack ofknowledge of the causes of diarrheaamong mother and caretakers, not withwater source or type of interventions haveproduced significant improvements inhousehold hygiene behaviors and a 38%reduction in child diarrheal July 1998, EHP convened aTechnical Advisory Group (TAG) onbehavior Change to review USAID /EHP experiences and assist EHP toidentify critical Environmental healthbehaviors at the community andhousehold level and to develop aframework for interventions to changethem.

10 EHP developed the lessonslearned on this topic through workconnected with the TAG andsubsequent Applied Study 10: Behavior First: A Minimum Packageof Preventive Behaviors to ImproveChild Health , which included anextensive review of the professionalliterature on the effectiveness ofbehavior Change to prevent diarrhealdisease and LEARNEDL esson One: Development ofa manageable package ofenvironmental healthbehavioral interventionshelps facilitate the integrationof Environmental Health inchild Health and others have developed anumber of standard preventiveinterventions to improve child healthand survival.