NTD NGO Network blog: Sustaining Behavior Change for the Prevention and Elimination of NTDs

Access to water, sanitation and hygiene (WASH) is a fundamental human right. Improvements in health and increasing life expectancy across much of the world can be attributed to investments that improve environmental conditions and healthy behaviors. However, inequities in accessing services mean that many of the world’s poorest and most vulnerable communities still lack sustained access to WASH infrastructure of sufficient quality. This leads to ill-health, including neglected tropical diseases (NTDs), which exacerbate social and economic challenges and can trap entire communities in a cycle of poverty and marginalization.

The presence of NTDs is an indicator of the need to improve access to WASH. Many NTDs, such as trachoma, soil transmitted helminths and schistosomiasis, are preventable through practicing the same behaviors, such as reducing open defecation, maintaining sanitation facilities, and hand and face washing with soap. Other NTDs require WASH access to treat the symptoms caused by the disease, such as personal hygiene to reduce the occurrence of acute attacks in people with lymphedema due to lymphatic filariasis.

How can WASH programs support NTD programs?

Ensuring access to clean water and sanitation facilities, such as working toilets linked with safely managed sanitation services and continuous water supply for hygiene purposes, is a critical first step, but is not enough. WASH infrastructure must be complemented by cross-sectoral integrated programs that bring health, education and WASH stakeholders together to raise awareness about the link between good health and hygiene and shift long-held cultural norms. In a nationally representative survey recently conducted in Uganda, researchers found that improved access to WASH facilities alone did not lower the prevalence of intestinal schistosomiasis. Rather, lower prevalence of the disease was associated with changing attitudes to open defecation and increased toilet use.

However, sustained behavior change is challenging. The complicated nature of disease transmission, which is influenced by both environmental and psycho-social conditions means that effective strategies are often extremely context specific. This is evidenced by the fact that systematic reviews have been unable to demonstrate replicable efficacy of any given approach.

So, what can we do?

The NTD community needs to invest in a coordinated program of research that investigates the determinants of healthy behavioral practices and designs and tests approaches that create and sustain change. Forums like COR-NTDs and ASTMH provide platforms for NTD stakeholders to share research outcomes and identify research questions for sustained behavior change.

Several theoretical frameworks have been developed in recent years to guide the design of effective interventions and ensure they are contextualized and appropriate to the communities they are designed to benefit.

The Behavior Centered Design framework is one such tool, developed by London School of Hygiene and Tropical Medicine and adapted by trachoma stakeholders to improve facial cleanliness and environmental improvements as part of the delivery of the World Health Organization endorsed SAFE strategy for trachoma elimination. The framework draws on psychology and marketing principles in order to explore and define the causes of behavior, including cognitive processes and the way individuals interact with their environments.

By using the framework’s environmental and psycho-social determinants checklist, those designing behavior change interventions can analyze behaviors that often go unexamined. For example, a study to understand the behaviors associated with trachoma transmission in Ethiopia found that communities practiced open defecation, in part, because open defecation was viewed as acceptable, comfortable, convenient and beneficial to agricultural productivity. In contrast, experiences with latrines were largely negative, with latrines perceived as smelly, unhygienic and dangerous for small children, leaving participants feeling poorly after their use.