Open Defecation - A Behaviour Change Communication Challenge | India on the Move

"Translating and effectively converting technical-information and complex socio-behavioral messages into creative, appealing and acceptable approaches that trigger sustained dialogue among participants is often one of the most difficult and daunting tasks within the design and delivery of...communication for development initiatives..."

This report shares the thinking behind, and results of, a qualitative study exploring the social and behaviour change communication (SBCC) interventions being employed in support of the government of India's open defaecation elimination (ODE) programme. Carried out by the Swachh Bharat Mission (Grameen), or SBM-G, this flagship sanitation programme will have completed 3 years in October 2017. However, a rapid survey conducted by the National Sample Survey Organization (NSSO) 2015/16 found that over half (55.4%) of the population in rural areas continue to defaecate in the open. OD is a key cause of growth stunting in rural India, and the lack of sanitation leads to the spread of diarrhoeal diseases - a leading cause of child deaths worldwide. To that end, social scientists argue that water, sanitation, and hygiene (WASH) strategies are fundamental to promoting and maintaining child health.

In examining conceptual frameworks and approaches informing their research, the authors describe the evolution from top-down communication strategies to those reflecting the understanding that members of the public are not passive recipients of information and that mass media alone cannot change people's perceptions, mindsets, and behaviours. They explain the evolution in the past 4 decades within the field of health communication from information, education, and communication (IEC) to behaviour change communication (BCC) and then to SBCC. They say that the dynamic inter-relationship between individual, family, community, and society that is at the core of SBCC is well illustrated through the Socio-Ecological Model in the communication for development (C4D) paradigm. However, "the choice of a suitable theory or a combination of theories under a strategic communication programme should begin with identifying the problem, goal, and units of practice, not just by selecting a theoretical framework." Rather, the designing of development communication programmes takes as its starting point both the "felt needs" at the social system level and the "action needs" as identified by development partners and key gatekeepers. This process involves people-centred, participatory methods of engaging communities in defining developmental and behaviour change goals, designing field-based activities, identifying required material and key messages, and building bridges with the local influential community-leaders.

"The importance of a community approach, especially so in promoting sustained practice of toilet-use and ending open defecation, cannot be overemphasized, especially in developing countries such as India. Social norms and pressures have a major influence on behavior, and this is a key not just in initiating behavior, but also for reinforcing it through feedback that makes successes visible and supports maintenance of the behavior. The idea that SBCC should appeal to emotions would seem to flow naturally from the idea that purely informational approaches are insufficient, but as is seen in many health and development interventions in developing countries, it is surprisingly absent in most programmes."

The authors conducted 8 focus group discussions (FGDs) in rural patches of 2 blocks of the district Ghaziabad (Uttar Pradesh, or UP) and 2 blocks of Muzzafarnagar district (UP) in order to: examine the availability of and access to varied communication channels/mediums, which are frequently used/accessed by the groups within the communities that the ODE programme seeks to reach; study the prevailing media habits of the communities, especially those who are considered as primary and first-level secondary audiences of the ODE programme; and understand people's perceptions about the perceived risk-factors viz. whether or not to regularly access toilets for defaecation. Selected results of the study follow.

Most respondents (approximately 75%) had access to television; however, watching TV was found limited to Hindi entertainment (films, serials and music channels), with a very small percent of respondents also tuning into Hindi news channels for short span of the time each day. Almost all the respondents recalled watching public service announcements (PSAs) by film stars Amitabh Bachchan and Vidya Balan on OD. Similarly, almost all the respondents immediately recalled hearing the Prime Minister (PM)'s message on OD over the TV during commercial breaks and the "Mann ki Baat" programme of the PM. A few male respondents, including young people, also correlated OD messages on TV with those of the billboards they recalled seeing in the district headquarters (HQs) or cities.

Access to and use of newspapers and magazines was extremely poor, as barely 15% of all the respondents say these are part of their media habit. Accessing radio was also found to be very poor (barely 15%) among respondents. None recalled hearing primary messages on OD issues over the radio. Nor did any of the respondents recal any handbills or booklets on the issues of OD. Close to 70% males and nearly 25% female respondents recalled seeing city and large town situated billboards on the issue. Some women members also recalled seeing very "text-heavy" posters on OD on the walls of Anganwadi (AWW) or primary school. Many young people, close to 40%, use smartphones and access internet on their mobile phone sets, yet they did not recall seeing any OD messages as such on the phones. They still mentioned seeing PM's message on SBM (OD) over social media.

Some members mentioned that on select occasions, especially on Gandhi Jayanti and other such national events, they heard local leaders (Panchayat members) mentioning "Clean India" (SBM) messages. Also, especially women respondents recalled health staff from the nearby centre emphasising cleanliness and sanitation as a requirement for prevention of seasonal diseases. Some mothers mentioned how their children often refer to schoolteachers emphasising use of toilets for hygiene and good health. None of the respondents actually recalled faith leaders referring to OD issues as a part of their discourses or discussions. Respondents mentioned visits of public health engineering staff in their respective localities, but most respondents did not recall engineering staff sharing awareness messages on OD issues.

The authors of the study, subsequent to documenting the series of FGDs through field enquiry, list select barriers and gaps in the OD programme, especially those bearing significant impact on how the SBCC ought to be designed and strategised. At the social and institutional level, for example, there is reportedly a continued lack of awareness regarding individual health benefits of toilet use and hygiene; information needs to be made more available in tribal areas and in local languages. At the individual/household, level, for example: "The habit of defecating in open has been passed on from generations, hence the rigid mentality and lack of adequate awareness regarding adverse impact of OD restricts many people regularly practicing toilet use." The authors of the study identified select key challenges with SBCC in practice that are based on the research findings:

• Most OD communication is material-centred, not stratified with behaviours and groups: Much of tge attention, time, and resources of the ODE programme has gone into the production of IEC materials (such as posters, billboards, and leaflets. Nevertheless, as is well known, attractive materials may help catching people's attention but do not necessarily convince people to make a strategic shift from current to the expected behaviour.
• Large focus on health benefits: As formative research studies have demonstrated, the most commonly used "driver" for OD elimination and hygiene promotion at the community level remains "health". However, the authors contend, this is rarely a sole trigger for behavioural change. Messages based on germs and health have been found to be ineffective (Biran et al, 2009). Evidence from various research studies show that social, physical, and emotional drivers (disgust, pride, loss of face, convenience, comfort, etc.) are some of the most common reasons households make a strategic shift of investing in toilets.
• Too many behaviours and audiences at a time: Many WASH programmes aim to address too many behaviours and audiences at a one given time period, without engaging in audience segmentation, prioritising messages, promoting cue-to-action, and stratifying communication tools, which can lead to low outreach and lower acceptance of positive behaviours. Evidently, scientifically designed, comprehensive, and integrated SBCC for WASH could yield results, provided the messages/channels/tools are well stratified and segmented. Strengthened interpersonal communication (IPC) also needs to be woven into the programme.
• Local line departments and key stakeholders with limited capacity in delivering SBCC: Almost always the primary messages under the ODE and hygiene are determined by the Central or Provincial teams in the Government. However, the adaptation and dissemination rests with the local governments and line agencies. Hands-on skills building and technical capacity development of the gatekeepers and key stakeholders in the districts should be integral to an effective and results-based SBCC for ODE.
• Social inclusion and gender equity and equality in SBCC: Some communication messages and materials tend to focus only on women as the primarily responsible for bringing and maintaining hygiene in the family. Seeking male support for substantial hygiene behaviour by all family members may have a decisive influence on the behaviour in the family. Thus, stereotypical images, such as exclusively positioning women teaching children how to wash their hands or women cleaning the family toilet, should be avoided. Communication experts and the design teams should balance these with images of men who also take a leading role in sustaining hygiene in the household.

The authors conclude: "WASH sector has some inherent and non-negotiable elements which, when put all together in addressing overall health & sanitation, shall constitute a holistic approach to 'Consolidated Social & Behavioural Change Communication for WASH' (CSBCC4WASH). These elements include: Hand-washing; Open defecation elimination; Waste disposal & treatment; Clean drinking water; Personal & environmental hygiene. Such an integrated and comprehensive SBCC for key WASH behaviours could only succeed provided the process is research-driven, scientifically designed, well stratified, audiences segmented and made community-owned. Upon deeper analysis of the current study, inter-dependence among the core WASH/SBCC elements and the expected community impact therein emerged that warrants further research and debate."

Click here for the 15-page paper in Word format.