Understanding Behavior Change for Safe Water: Psychosocial factors in Pakistan

The Health Communication Partnership

End-of-Project Meeting October 2, 2007

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 Handwashing

Washing & Covering

Purification & Storage

Food

Adapted from EHP, 1999. Preventing Child Diarrhea Disease, Options for Action. Advancing Health Communication, Saving Lives

Family

Transmission barriers

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

Knowledge

Personal Advocacy
Social Support & Influence Emotions

Attitudes

Implies simultaneous effect of all influences.

SelfImage

BEHAVIOR
Perceived Risk SelfEfficacy Norms

Implies communication can affect all influences.

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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

1. Attitudes toward water treatment 2. Knowledge of water treatment methods 3. Social influence:
Talked to husband, husband supports, talked to others, others have recommended, has advocated to others

4. Perceived norms
Relatives or friends treating water at home
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Five positive attitudes toward water treatment 1. Water that looks clear is good for drinking*
2. Piped water needs to be treated. 3. I only trust the water that I have treated myself. 4. Sweet tasting water is good for drinking* 5. 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

80 60

67 46

40

23
20

15 6

0 1-1.5 1.5-2.5 2.5-3.5 3.5-5 Overall

Four Attitude levels (scale 1-5)

K=5 items; N = 1,500
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Percent treating water by number of methods known. Sindh, 2005

Percentage

80 60 40

32 23 15 0 15

37

36

35

37

20 0

None

Methods known (spontaneous and aided)

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

80

63
60 40

62

60

34 23 9
None 1 2

35

20 0

Six levels of social influence

K=6 items; Cronbach alpha = 0.87; N = 1,500
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Percent treating water by level of perceived norm. Sindh, 2005

Percentage

100 80 60 40 20 0
None About half or Less

86 65

14
More than half, Almost all

Three levels of social norms

Cronbach alpha = 0.94; N = 1,500
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Percent treating water by type and number of psychosocial index. Sindh, 2005
Knowledge 80 60 40 20
Percent

Attitude

Soc Influence

Social norm

65.6

35.2
17.2 7.7

1.6
0 1 2 3 4

Number and Type of Psychosocial Factors

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Regression of treating water at home on psychosocial factors and selected control variables
Variable
Psychosocial factors (0-4) Dirty latrine (0-4, 4 dirtiest) Piped water % Surface water (river, pond) % Perceived water quality (1-5, 5 very good) Store water at household % Number of women in household

Odds ratio
1.23*** 0.70*** 3.01*** 2.47*** 0.75*** 1.48* 1.38*

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. N=1,500, Chi 2 (p,.001) *** (p<.001), * (p<.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

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