Understanding Behavior Change for Safe Water: Psychosocial factors in Pakistan

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• Understanding Behavior Change for Safe Water
  Psychosocial factors in Pakistan

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• USAIDs Global Development Alliance

Safe Drinking Water Alliance
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Why should we care about water treatment
behavior?

• Poor water quality continues to be a major health
  threat.
• Diarrhea alone kills about 5 000 people, every
  day, most of them young children.
• Most of this problem, the result of unsafe water,
  poor sanitation and hygiene.

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Fecal-Oral Transmission Cycle
Feces
Traditional Latrine
Flush Latrine and Toilets
Water
Fields
Flies
Hands
Washing Covering
Handwashing
Purification Storage
Food
Family
Adapted from EHP, 1999. Preventing Child
Diarrhea Disease, Options for Action.
Transmission barriers
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Improved water source and safe water

• 1.1 billion people lack access to improved water
  sources
• Recontamination due to transportation and storage
• Treatment at the household level, about 2x as
  effective as treatment at the source

WHO, 2007 Clasen, 2005
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POU water treatment technologies

• Boiling
• Filters
• Chlorination
• Chlorination and
• flocculation
• Solar disinfection,
• Others (UV light)

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• Water treatment not a sustained practice for
  people that need it most

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Findings of literature review on water treatment
interventions

• Focus on technology not the consumer
• Main message in the last 50 years
• contaminated water causes diarrhea
• Mothers believe diarrhea due to
• teething, growing up, eating raw or green fruit,
  cold-hot foods, evil eye.
• Some see a benefit (cleans the bowels)
• Diarrhea prevention, not a clear benefit for
  mothers!

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Reasons why people treated water (boiled) in Peru
in 1955

• They were ill, and the norm was that ill people
  drink boiled water,
• They considered themselves of higher status,
• They had empathy with the health promoter,
• An authority a trusted source recommended them
  to boil water
• The 2-year intervention promoting boiling to
  prevent diarrhea failed!

Wellin, 1955
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A predictive model of communication
change Influence of psychosocial factors on
behavior
Implies simultaneous effect of all influences.
Knowledge
Personal Advocacy
Attitudes
Self-Image
Social Support Influence
BEHAVIOR
Perceived Risk
Emotions
Implies communication can affect all influences.
Self-Efficacy
Norms
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Field Work in 2005

• Qualitative research identified psychosocial
  factors in the province of Sindh, Pakistan
• Household survey with 1,500 women who had
  children under 12 economic strata C-E

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Four Psychosocial factors investigated. Sindh,
2005

• Attitudes toward water treatment
• 2. Knowledge of water treatment methods
• Social influence
• Talked to husband, husband supports, talked to
  others, others have recommended, has advocated to
  others
• Perceived norms
• Relatives or friends treating water at home

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Five positive attitudes toward water treatment

• Water that looks clear is good for drinking
• Piped water needs to be treated.
• I only trust the water that I have treated
  myself.
• Sweet tasting water is good for drinking
• Good health comes from God and not from what
  people do to keep healthy

Inverted items. 5-point scale of level of
agreement. N 1,500 women. Attitude score k
5 Cronbach alpha 0.60
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Percent treating water by level of positive
attitudes. Sindh, 2005
Percentage
K5 items N 1,500
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Percent treating water by number of methods
known. Sindh, 2005
Percentage
Survey investigated 8 methods boiling, chlorine,
PUR, Dettol, cloth filter, other filter, alum,
solar, N 1,500
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Percent treating water by level of social
influence. Sindh, 2005
Percentage
K6 items Cronbach alpha 0.87 N 1,500
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Percent treating water by level of perceived
norm. Sindh, 2005
Percentage
Cronbach alpha 0.94 N 1,500
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Percent treating water by type and number of
psychosocial index. Sindh, 2005
Percent
65.6
35.2
17.2
7.7
1.6
Number and Type of Psychosocial Factors
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Regression of treating water at home on
psychosocial factors and selected control
variables
Other control variables include sociodemographic
(age, education, religion), number of children in
household, spouses occupation, participation in
community groups, access to media, household
hygiene (soap in handwashing area, dirty
household), type of latrine, time to collect
water. N1,500, Chi2 (p,.001) (plt.001),
(plt.05)
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Conclusions

• Psychosocial factors strongly associated
• with water treatment in Sindh, Pakistan
• Design communication programs that
• promote these factors rather than focusing
• on diarrhea alone
• Positive attitudes, better predictors of
• water treatment than negative attitudes
• Preferred attributes of water should also be
• used to promote water treatment.

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Promotion Strategy for Pakistan
Safe water promoted with positive attitudes

• Healthy and well nourished children
• Take responsibility
• You can trust water you have treated yourself
• You can find the time to treat your familys water

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Another promotion approach
Safe water promoted with preferred attributes

• Sweet tasting
• Shiny and clear
• Safe
• Natural
• Affordable
• Easy to use