Tag Archives: behavior change

Insights from personal observations and interactions with two ethnic communities in Sekong province.

September 30, 2015. By Cecile Lantican.

Sekong Province, Lao People’s Democratic Republic – Early in the morning, our team traveled to Sekong province. With less than 100,000 residents, Sekong is the second smallest province in Lao. It is also one of the poorest. Sekong province is located in one of the most remote areas in Lao: most of the province’s 42 villages are inaccessible by road because the infrastructure has been poorly developed.

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Sekong province, Lao PDR

Our mission was to pre-test communication campaign concepts, materials, and messages for the Lao government’s sanitation program among representative audiences in two rural communities. The district coordinator of the Center of Information and Education for Health (CIEH) arranged for our group to meet villagers of Toungkeo in the Lamam district. Lamam, which means “lowland plain,” is one of the four districts in the province.

The ferry we took en route to Ban Tok Ong Keo.

The ferry we took en route to Ban Tok Ong Keo.

From the ferry station, we drove through rugged terrain and winding mountain slopes. We passed by three small streams that indicated the richness of the water reservoir further up in the hills. It was almost midday when we finally reached Ban Tok Ong Keo. Four staff of the village health center greeted us and joined us for a quick packed lunch.

One of the streams we passed.

One of the streams we passed.

Nestled in between the undulating mountain slopes, the village was covered by lush vegetation following the recent rains. The air was hot and humid. We noted electrical posts in the village, but none of the houses were connected to the main lines. There was no mobile signal and our phones did not work. Considering the distance we traveled, I could imagine how tedious and expensive it would be for latrine sales agents or businessmen to travel here with their latrine products and supplies.  Sales agent never reached this village.

Sekong province is very remote.

Sekong province is very remote.

Almost all of the houses followed a similar construction design: they were made of wood and standing on stilts. Under the houses, we noticed piles of firewood and free-range animals like pigs, goats and cows. Villagers also use the space under these houses as work and rest areas.

A typical house in Ban Tok Ong Keo.

A typical house in Ban Tok Ong Keo.

We proceeded to the house where we would meet our pre-test participants, who had been waiting for us since that morning.

Ethnicity and Language

Sekong province is ethnically diverse. There are 14 ethnic minority groups, and only three percent of the population is Lao Loum. While the government verbally recognizes the use of ethnic languages, it officially encourages people to read and write only in ethnic Lao Loum.

Village women and children.

Village women and children.

 These villagers belong to the Alak ethnic minority, which reportedly constitutes 21 percent of the province’s population. The government categorically includes them among the “Lao Theung” ethnic group, the “mid-slope Lao.” The Alak women are known for weaving unique and high quality Lao “sin” (skirts).

A group of 12 women was assembled to meet us in one of the houses.  The field coordinators explained that people are shy about talking to foreigners, so we did not ask for their names out of respect for cultural sensitivity. Instead, we noted their ages and education levels. We asked the most senior woman her age.  She said,  “I [am] maybe between 50 to 60 years old.” She could not remember her birthday. This is common among Laotians; people do not always know their birthdays and in practice, a majority do not celebrate birthdays. When asked about the names of her 19 children, she could not remember them all.  But she claimed that all 19 children and her grandchildren from her three married daughters are living with her in one house.

Women participants in Ban Tok Ong Keo.

Women participants in Ban Tok Ong Keo.

Most of the women pre-test participants spoke limited Lao language. Only three women could read Lao characters. These women reported that they had reached fourth grade in the primary school before leaving school. The rest of the women had reached only the second grade.

The government built their houses. This could explain why the majority of the houses had similar architecture. One elderly male neighbor said,  “A few years ago, the government resettled us to our present location. We used to stay in a much lower ground along the river. But every time it rained, the river overflowed. We experienced flooding.” As a result, the government built their houses in higher plains and provided gravity-fed water to a cluster of households.

The government also built a latrine for every family. But as the number of families grew over the years, others did not build more toilets. Older villagers in particular reverted to open defecation.

A government-built latrine.

A government-built latrine.

In the neighboring village of Ban Nava Kang, we met eight Alak women. None of them had attended school. They could speak very limited Lao, but could not read Lao characters. Two of the older women were asked of their age. Like the older woman in Ban Tok Ong Keo, they could not also tell us their real ages and birthdays.

Households in this village do not have latrines. We were informed that everyone goes to the open field to defecate. This observation was validated by our pre-test materials.

 Rethinking our BCC Materials and Messages for Sanitation

Among the four communities where we tested the proposed campaign concepts, messages and materials, the responses of villagers from Ban Tok Ong Keo and Ban Nava Kang led us to believe that open defecation is strongly related to factors specific to the culture of groups that practice it. The Alak villagers we met have particular ways of thinking about latrines, and they reacted to situations or events as they understood them.

Men participating in our pre-test.

Men studying our initial communication materials.

The Alak villagers of Ban Tok Ong Keo did not maximally use the pour-flush latrines built by the government. The men respondents suggested the following reasons for this disuse:

  • It is a hassle to collect water before defecating.
  • The water source is too far from their houses.
  • They would need to carry a lot of water because they have to clean the latrine after using it. If they do not clean it, it will smell bad because it is near their house.
  • They prefer to defecate in the open because they can do so easily. Feces will dry up quickly outside in the heat, rather than in a confined and unpleasant-smelling toilet.
  • They worry that neighbors will notice them walking to use the toilet.
  • They prefer the privacy offered by defecating in the bush instead of at home.

The Alak men agreed that latrines would help ensure their daughters’ safety, but the current structure of their toilets does not offer privacy. The Alak women of Ban Nava Kang told us that our visual showing the girl who feels the need to relieve herself was a woman who feels the pain of giving birth. After further probing, one of the women associated the girl’s stomach ache with “diarrhea” from eating unclean food.

Pre-testing our communications materials.

Pre-testing our communications materials.

These two Alak communities showed us that having a latrine was not among competing priorities of their daily needs. The open field where they defecated was seen as more convenient than a latrine. The open field was big, unlike the very small, closed, and hot latrines.

Open defecation has been part of their culture. It is a behavior that they have acquired over time. Hence, these communities could be resistant to changing their sanitation practices. They may choose to stop open defection, but it may take time.

The environmental conditions surrounding these villages further shaped their attitudes in favor of open defecation. In Ban Tok Ong Keo, the geophysical conditions of the village make latrine construction difficult. The soil can be too hard, and the ground water is sometimes too low. Thus, villagers were not motivated to construct new latrines.

This pre-test experience taught us valuable lessons about our communication approach to change sanitation practices among ethno-linguistic populations. It led us to strengthen the effectiveness of our approach by making it adaptive to specific local contexts.

Initially, our team agreed that a communication campaign to improve the sanitation practices of Lao communities like the Alak would require:

  • Determining the socio-cultural beliefs and ecological/environmental context of target communities,
  • Identifying the relevant communication networks, decision-making processes, and social leadership that could be utilized by the community to facilitate change, and
  • Identifying and building the capacity for trusted sources of information in the community.
CAPTION

We left Sekong province with valuable insights.


The National Centre for Environmental Health and Water Supply together with the World Bank’s Water and Sanitation Program and other development organizations have partnered with Another Option, LLC to create a series of communication products that will help to inspire the use of improved sanitation facilities in rural areas.

By Shane Powell.

Champassak province, Lao People’s Democratic Republic – Traveling the last stretch of road to Pha Kha village feels like looking out the window of an airplane that’s just broken through storm clouds and been greeted by a rich, blue sky.

Wet-season rice paddies – the road leading into Pha Kha village. Photograph by Judy Souvannavong.

Miles of dusty, potholed roads suddenly give way to vast fields of fluorescent-green rice paddies. The scene sweeps calmly to the horizon in every direction, broken only by streams and scattered, flattened rocks positioned like small islands.

Noy, 19, has spent most of her life in Pha Kha village, together with her mother and older sister. She says she likes the clean air and relaxed pace and she wants to raise her 9-month-old son here with her husband.

But having recently spent two years, caring for her younger cousins in the country’s capital city, Vientiane, Noy explains a few things she had to change once she returned home.

Noy, whose name means ‘small’ in Lao language, has helped to trigger big changes in her community in southern Lao PDR. Photograph by Cecile Lantican, Ph.D.

Noy, whose name means ‘small’ in Lao language, has helped to trigger big changes in her community in southern Lao PDR. Photograph by Cecile Lantican, Ph.D.

“I never realized how convenient having a bathroom would be,” she explains. “When I came back (from Vientiane), there was no way I was going to continue going into the fields. It was so uncomfortable.”

Noy uses the words ‘uht aht’ to describe how she felt at losing the convenience and dignity she previously had in Vientiane, forced to find a tree or bush to crouch behind. Roughly translated, the words connote the feeling of having an awkward itch that you can’t scratch.

“I told my mother ‘we’re building a bathroom’,” she says, recounting how her decision “was final”. A few weeks later, her husband and brother-in-law had finished building a brick bathroom just next to her home.

“Noy told us we had to have one,” her mother recalls. “At first, I didn’t really think it was necessary… I thought we should spend the money on something else. But now I can’t imagine not having it… And I wouldn’t want my daughters having to go without one.”

Noy’s family latrine was built in early 2014. Neighbors followed suit in their own construction of latrines, significantly raising sanitation standards in the surrounding community. Photograph by Judy Souvannavong.

Noy’s family latrine was built in early 2014. Neighbors followed suit in their own construction of latrines, significantly raising sanitation standards in the surrounding community. Photograph by Judy Souvannavong.

It wasn’t long before Noy’s neighbors also started building bathrooms. A construction salesman who lives just up the hill from her started designing a series of connected latrines and washrooms for his family that now rivals the size of smaller homes in the village.

While sending all the young women in such a village off to spend time in bigger, developed cities is not likely the answer to inspiring better sanitation in rural areas, Noy – whose name literally translates as ‘small’ – is a good example of how one person can start to catalyze a community.

“It’s happening now… it’s slow, but it’s happening,” explains Mr Bounpone, the head of the cluster of communities of which Pha Kha village is a part.

But arguably the movement to build latrines in Pha Kha is not so slow. It was just two years ago that the community had less than five latrines for more than 150 households. Today, the community has 78. Village authorities estimate that if solutions can be found to some of the village’s water problems, nearly every home will likely have a latrine in two more years.

“We want the status of having a clean and healthy village,” Mr Bounpone says. “The people here see others building latrines and they want them too. For some, it’s still a matter of money. For others, we first need to work on the locations for them to build.”

This is precisely the type of progress and development that the Lao Government’s Ministry of Health (MoH) wants to see in rural areas.

“We know that with the right inspiration, people will take ownership for their family and their community’s health,” says Dr Bouakeo Souvanthong, Chief of the Environmental Health Division in the National Centre for Environmental Health and Water Supply under MoH. “But it will take people seeing and realizing the benefits of a few, before it spreads to many.”

As for Noy, she says there are other conveniences she misses from living in a larger city. “Ease of shopping… some of the food… and nobody wanting to use my bathroom,” she laughs. “If (my neighbors) keep using this one, it’s going to overflow!”


 

The National Centre for Environmental Health and Water Supply together with the World Bank’s Water and Sanitation Program and other development organizations have partnered with Another Option, LLC to create a series of communication products that will help to inspire the use of improved sanitation facilities in rural areas.

Shane Powell is a communication specialist who has worked on behavior development issues for more than 10 years in Southeast Asia. His areas of work focus on health, nutrition, education and natural resource protection. Shane currently resides with his wife and two cats in Vientiane, Lao PDR where they maintain vast collections of tea and soap from around the world.

It is easy to forget that behavior change theories and principles can be applied effectively to energy conservation and climate change as it is to disease prevention.

What is amazing to me is that what we’ve been doing in global and domestic health for more than 40 years has not crossed over into the energy and environmental sectors as much as it should have.
This became apparent when I participate at a panel session at the American Council for Energy Efficiency Conference in Baltimore on 31 March.

As background, Another Option was invited by its colleagues at Cadmus to be on the A Shift in Perspective: From Measures to Customers panel and to present examples and experiences of successful behavior change from another sector. Public health has been applying behavior change for years and that’s our primary sector….so it was quite fun and revealing to participate.

Though I’ve done behavior change for energy efficiency and climate change in Africa what I learned at the conference about US consumers was very interesting:

I learned there are over 21 actions a person can take to be energy efficient….wonder how many there are for staying healthy?
But several of these are one-time behaviors…such as recycling old appliances, participating in a home energy analysis, or upgrading HVAC and water heating systems. Then there are the others that require on- going actions — controlling electrical use, purchasing the energy efficient appliance, and buying and loving the new light bulbs.

On paper it seems so obvious because economics or policy have changed our selection options or pocketbook choices. Appliances are more efficient in its water and heating usage; the new light bulbs have replaced the old amid grumbles and complaints; and energy isn’t cheap so keeping the windows closed and thermostat down is a no-brainer.

But for the other less regulated choices the energy companies need to know more about their consumers and users. What has been missing is an analysis of solid consumer research and segmentation by practices and behaviors, gender, geographic areas that tell us about the energy consumers and the environment that they live in – whether it supports or discourages good consumers’ behaviors.

This attention to understanding consumers is a fairly recent trend for the energy efficiency sector, and there was great interest in the programs discussed in the session. But it still is a hard sell. As it was in health. Even now we hear “just tell them and they’ll do it.”

Hmmmm….I don’t think the data supports that.

energy efficiency

How nice to see the New York Times editorial supporting the Global Health Security Agenda and urging the United States Congress to authorize this bill.

A nasty, scary virus.

A nasty, scary virus.

It is important, yes.  There are reminders in the news and incident rates creeping up of neglected diseases as well as viruses most of us don’t know from our childhood, like measles and polio  — but that’s fodder for another blog.

Hugs and praise to the NYT for coming out in favor of investing in prevention of infectious diseases.  Yet I did read the editorial with a sinking feeling of frustration that it cast this Agenda with fear and catastrophe. In worst case scenarios harm from disease can grow to horrific proportions but the reality is slim. Not everyone is at risk and scaring people doesn’t work, or work to the degree that will make  us change our behaviors and practices to make a difference.

Show of hands: Who isn’t exercising enough or is still smoking ,though the public health experts have pounded us over the head with fear campaigns promising that we will die an ugly death if we don’t stop?  Yep, that’s what I thought. We persist, even though research shows that fear theory doesn’t work.

One of my good friends and respected colleagues said neglected tropical diseases lost the marketing battle with its name. It doesn’t instill confidence, does it?

Let’s change things starting with a positive preventative Agenda.  Let’s talk instead about the benefits and value of taking action before we need to go into response mode, rather than attempt to scare the masses. It isn’t correct or fair and, sadly, it misrepresents the benefits of an ounce of prevention.

Dee Bennett

It’s like watching a train wreck: you can’t quite look away, but it’s painful to watch.

Richie_Incognito_Jonathan_Martin

Richie Incognito and Jonathan Martin, of the Miami Dolphins; Credit: AP

All we want to do (and it is all about us, isn’t it?) is watch a football game. We don’t want to be distracted knowing that our favorite “bad guys” may be damaged goods or that this aggression comes from somewhere other than winning the game.

But with the past week’s news on the alleged harassment within the Miami NFL team, we are forced to go into the locker room and recognize the culture that allows, encourages, systematizes—pick a word—this negative behavior.

I had lunch yesterday with a good friend and professional colleague and this story came up. Since we work on gender-issues in international development, it was rather obvious to us that the only way to change negative behavior towards gender is a massive change in the environment that tolerates such behavior. The best way to make this change  is through policy and the strict enforcement of that policy.

Are you listening, NFL?

Think about this: If we spend the majority of our time at work in comparison to the time we spend at home or play—whatever “play” is—it is logical that our behaviors at work would dominate or influence our life.

I remember seeing an article once that asked people, Would you want your children to see how you behave or act at work? Many said no.

Understood.

So I find the NFL now struggling with a situation of alleged harassment or bullying. In interviews with other professional football players about this incident, their response are: “ This is how things are in the locker room. What happens in the locker room, stays in the locker room.” These responses sound eerily like those we hear in so many countries where rape and abuse are considered allowable offenses that are culturally condoned.

Just because it is what has been done doesn’t mean it is right or should be tolerated. Whether it is the NFL’s, or any professional sport’s, aggressive and hazing practices or rape as a political tool for control.

Behaviors—negative or positive—are not easily turned on and off. And a quick survey of behavioral literature will tell you that the negative behaviors in the locker room or work place spill over into domestic and civilian life.

I’d like to think the NFL case is the opportunity to make necessary changes and in so doing influence other work environments, proving that good behaviors also win games.

Ok. I will admit. I have a crush on Atul Gawande.

I love his book, The Checklist Manifesto and his no-nonsense approach to avoiding medical errors which plague health facilities in the US.

Rather than pointing fingers he provides a practical tool for hospital staff to ensure all steps are covered during hospital procedures.

In his recent article in the July 29th New Yorker, SLOW IDEAS: Some innovations spread fast. How do you speed the ones that don’t? http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande Gawande examines how important global health practices can “stick” given the right approaches and tools.

As someone who has been following the literature and practice of behavior change for 30+ years, such a treat to come across this article that succeeds in explaining behavioral theory, research and practice in one easily digestible, non-academic article.

The big take from Gawande’s article….

The gold standard for behavior change is positive personal interaction. High touch (personal interaction, mentoring, one-to-one instruction) interventions in many cases can be more effective than low touch (mass media, instructional curricula, and technology) interventions.

So in keeping with his checklist approach I will share with you my checklist from his article:

1. Observe and understand the context for why a behavior is or isn’t being practiced
2. Learn why people are doing what they are doing- and what is getting in the way of doing things the right way
3. Don’t assume that technology is the best solution (especially in global health)
4. Instructions (a checklist) followed by careful mentoring can reinforce positive behaviors for health professionals
5. Mass media is helpful to sustain a behavior over time
6. Community interventions that require a community learning a new practice need: individual interventions that demonstrate the practice; observations of community members trying the practice and monitoring of the practice over time.

I’m eagerly awaiting his next book.