Affiliated organizations : USAID, The Manoff Group, Global Communities
Type of publication : Research and Learning Brief
Date of publication: March 2021
Years of effort and focus by the Government of Ghana and its partners have yielded significant improvements in the country’s child morbidity and mortality rates. Still, every year, at least 4,000 Ghanaian children die from diarrhea, and 23% experience chronic malnutrition linked to poor water and sanitation.
The project objectives for the seven-year Water, Sanitation and Hygiene for Health (W4H) project are to: (1) Increase use of improved household sanitation; (2) Improve community water supply services; (3) Improve sector governance and policies; (4) Expand the practice of key hygiene behaviors; (5) Leverage public-private partnership investment to magnify the impact of USG funding; and (6) Improve water supply and sanitation infrastructure for schools and health facilities.
In its sixth year, Ghana WASH 4 Health applied an approach to behavior-led programming called Behavior Integration to all project objectives. Evidence was gathered through behaviorally focused formative research to confirm the selected priority behaviors and to map pathways to changing these behaviors. In its seventh and final year, the project conducted an impact assessment of Behavior Integration, measuring its ability to impact behaviors over a period of nine months.
Though these findings are not an indication of the sustainability of the changes in behavior, they do demonstrate that the initial change in behavior does not need to take years, only months.
Priority Behaviors Selected
The project’s strategy was designed to promote the following priority WASH behaviors:
- Caregivers in households of children under five properly use and maintain an improved household latrine
- Caregivers of children under two safely dispose of their children’s feces in a latrine
- Caregivers in households of children under five wash hands with soap under running
water before eating and after defecating
- Caregivers in households of children under five treat, store and retrieve drinking
- Caregivers create a clean space for their children to eat and play
- Caregivers handle their children’s food safely
- Caregivers wash their hands before handling food for their children and wash the
hands of their children before they eat
- Mothers exclusively breastfeed for the first 6 months
- Clients drink safe water at health facilities
- Basic school children wash their hands with soap under running water before eating
and after defecating at school
The resulting strategy reflected that behavior change occurs within a system that requires structural, social, and internal factors to be addressed or leveraged; and that institutional, community, and family supporting actors are identified to support the adoption of behaviors.
For the priority behavior, “Caregivers in households of children under five properly use and maintain an improved latrine”, the sub-behavior, “Caregivers in households of children under five maintain their improved household latrine properly, including clearing the surrounding area of weeds and scrubs, and repairing the outside as needed,” increased 18%.
The sub-behavior, “Caregivers in households of children under five dispose of the children’s feces in their improved household latrine,” increased 11%. The sub-behavior, “Members of households of children under five use their improved household latrine properly including cleaning it regularly and clearing it of flies,” increased 4%.
Sub-behaviors of the priority behavior, “Caregivers in households of children under five, wash their hands at two critical times,” showed marked improvement over this nine-month period. The sub-behavior, “Members of households of children under five, wash their hands with soap under running water before eating,” increased 37%; while the sub-behavior “Members of households of children under five wash their hands with soap under running water after defecation,” increased 26%.
These initial findings indicate that the project’s approach to behavior change, known as Behavior Integration, can yield changes to entrenched obstacles and increase the likelihood of WASH behavior change in months, rather than years.
- The project assessed the impact of select behavioral objectives over a nine-month period in the final year of the project.
- In households with children under five, practice of behaviors related to the safe storage and proper retrieval of drinking water increased 13% and 34%, respectively;
- The use, maintenance of improved household latrines and proper disposal of child’s
feces increased by more than 4%, 18%, and 11% respectively; and
Handwashing with soap under running water at two critical times (before eating and after defecating) improved by more than 37% and 26%, respectively.
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