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Skip to 0 minutes and 12 seconds By the end of this presentation you should be able to: - Appreciate the role of behaviour change for F&E - Describe a theoretical consideration in behaviour science - Assess the behaviour centred design framework and the role of interventions to disrupt behaviour settings - Appraise the approach for behaviour change application in trachoma endemic communities As part of the SAFE strategy, facial cleanliness and environmental improvement are essential public health changes to reduce the transmission of trachoma. In the first instance between family members and then amongst the wider community. Several specific practices associated with the collection and use of water are related to trachoma transmission

Skip to 0 minutes and 55 seconds within trachoma endemic communities: - washing and wiping of faces - human defecation and disposal of faeces - animal husbandry and disposal of faeces - household waste disposal - fly control - sleeping arrangements - laundry.

Skip to 1 minute and 14 seconds It is important to consider for each of these practices: Who carries out these behaviours? Where and what with? What is the existing knowledge about trachoma? Does it motivate and influence practice to avoid the disease?

Skip to 1 minute and 31 seconds Simply providing clean water sources or toilets, or putting up posters about face cleaning, may not translate into a sustainable influence to change practice. Interventions must also be acceptable and feasible for the community. Context specific F&E interventions, based on local evidence, have the potential to support behaviour change and, alongside surgery and antibiotic provision, eliminate trachoma in endemic communities. Let’s begin by trying to understand what influences human behaviour. The dynamics of this are complicated and multifaceted. Behaviour is the purposeful and dynamic interaction over time between people and their environment. In the evo - eco model, behaviour is influenced by three types of environment. - The physical environment - that is objects and the infrastructure.

Skip to 2 minutes and 21 seconds For example, the availability of water and soap - The biological environment For example, animals or flies seeking discharge on faces - And the social environment - these are people’s relationships and networks. For example, sharing bedding or wash cloths. When a person experiences any of these environments,

Skip to 2 minutes and 42 seconds the result is a behaviour that can be: - Reactive - that is done without needing to think. For example mothers may subconsciously wipe their child’s face - Motivated - done because of emotions and interests. For example, being disgusted by a dirty toilet or a mother being less disgusted by discharge on her own child’s face - Executive - this is assessing and understanding the change. For example, stopping defecating in the open in order to prevent flies. Interventions that we consider essential must therefore link the environment with people’s minds and bodies. The practical application of behaviour science is called Behaviour Centred Design.

Skip to 3 minutes and 25 seconds BCD provides a theoretical framework on how a selected intervention produces a change in the environment, which influences a change in the minds of the target audience, which results in behaviour change. In the context of trachoma elimination, interventions aim to create changes which result in better eye health and reduced transmission of transmission. For example let’s consider a trachoma endemic community

Skip to 3 minutes and 48 seconds where: - Face-washing, or wiping away discharge from young children’s faces, is rarely practised - Parents and children are highly affectionate and often come into contact with discharge - And, wiping of faces is with hands or children’s clothing. The behaviour intervention would first require a detailed

Skip to 4 minutes and 7 seconds assessment of each of the three types of environment: - Physical - the local access to water - Biological - influences on transmission of disease from discharge by flies and direct contact - Social - face-washing in young children may be thought of as not normal, wasting water or even unachievable. To disrupt the existing behaviour setting and achieve a change may require multi-directional manipulation of the three types of environment. Behaviour Centred Design takes a five stage approach to achieve

Skip to 4 minutes and 41 seconds a desired disruption of a behaviour setting: - Assessing what is known and what is unknown about the desired behaviour. For example what are individuals’ and the community’s views on face-washing or the presence of discharge on faces? - Build or fill in the gaps by collecting data on local knowledge and practices - Create intervention materials and concepts that will have an impact.

Skip to 5 minutes and 5 seconds For example, messages, emotional demonstrations or posters - Deliver: Expose the target population to the activities - Evaluate: to determine if the predicted environmental, psychological and behavioural change has occurred To achieve the desired impact, the challenge is to create an appropriate intervention to modify the environment. Firstly, the intervention should cause a sense of surprise and gain the attention of the target population. For example, adding face-washing onto existing routines for children such as before eating when water is also available Then, it should cause each person to revalue their response or behaviour. For example, an increased sense of disgust when seeing discharge on a child’s face And finally, the intervention should support the performance of change.

Skip to 5 minutes and 56 seconds For example by making face washing an enjoyable and comforting activity for the whole family or within a school setting. Through behaviour change, the F component in trachoma

Skip to 6 minutes and 7 seconds programmes aims to achieve: - Face-washing, at least once a day (especially in children) - Face-drying or wiping with a clean cloth - Avoidance of sharing cloths or pillows - Hand washing with soap. Behaviour practices for the E component are regarded as much more than constructing latrines.

Skip to 6 minutes and 28 seconds They include: - Proper disposal of human faeces (the use of toilets) - Keeping toilets clean, functional and accessible - Keeping living spaces free of faeces both animal and human - And keeping household waste in a covered area. At a community level behaviour change is also targeted

Skip to 6 minutes and 48 seconds towards: - Empowering people to demand quality water and sanitation infrastructure - Being active in mass drug administration and taking the antibiotics - Undergoing surgery as required.

Skip to 7 minutes and 2 seconds In summary: - People’s behaviour is influenced by their environment - Behaviour change therefore requires a disruption within the setting - The disruption is a planned behavioural change designed specifically for the local context and achieved through the ABCDE approach - Sustainable results need to be structured as long term and not short term goals. F&E must be done in partnership with other activities for NTDs and WASH. And they must be guided by national policies.

Behaviour change for F&E

Behaviour change cannot be approached as an isolated intervention. Behaviour is a response to a specific environmental setting, within which defined roles and activities are performed. Change is a long term commitment and can be achieved only through change in the behaviour setting itself.

Promoting individual towel use in Nepal

As in some other countries in Asia and North Africa, people in Nepal often use a washcloth to clean their faces. All the children in selected nursery schools in the Far West region of Nepal have been given their own washcloths. The cloths are labeled with a picture so that each child can recognize his or her own, and labeled with names to aid the teachers. The children wash their faces when they arrive at nursery school in the morning and then again after their games and activities outside.

P Emerson et al. Implementing the SAFE Strategy for Trachoma Control. The Carter Center

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