Sociopsychological determinants for safe drinking water consumption behaviors

Socio-psychological determinants for safe drinking water consumption behaviors: a multi-country review Prof. Dr. phil. et dipl. zool. Hans-Joachim Mosler MSc. Jonathan Lilje Environmental and Health Psychology Environmental Social Sciences mosler@eawag. ch Eawag: Swiss Federal Institute of Aquatic Science and Technology

How can we understand behavior? Promotion of Behavior Person Behavior

How can we understand behavior? Promotion of Water Disinfection Person Factor A Factor C Factor B Factor D Behavioral Factors Drinking disinfected water Need to know these behavioral factors

Promotion of Water Disinfection Psychology is the Science of Behavior Person For knowing the relevant behavioral factors we should use Health Psychology Only studies which used behavioral psychological theory Factor A Factor C Factor B Factor D Behavioral Factors Drinking disinfected water

The objectives of this review are 1. to show whether by using psycho-social determinants safe water consumption practices can be explained sufficiently well 2. to identify determinants which are with great probability useful to be targeted in all environmental and socio-cultural contexts to recognize determinants which might be specific for different populations to detect determinants which probably are specific for different safe water practices 3. 4.

We identified a total of 15 studies using health psychology in a quantitative way for explaining safe water consumption behavior Theories encountered: Ø Health Belief Model (HBM) (Rosenstock 1974) Ø Protection Motivation Theory (PMT) (Floyd, Prentice-Dunn & Rogers 2000) Ø Theory of Planned Behavior (TPB) (Fishbein & Ajzen 2010) Ø Health Action Process Approach (HAPA) (Schwarzer 2008) Ø RANAS Model (Risk, Attitudes, Norms, Abilities, Self-Regulation) (Mosler, 2012) Types of safe water consumption behaviors § 9 studies household water treatment: 5 solar water disinfection, 2 boiling, 1 household level filter usage, and 1 chlorination. § 5 studies on switching to safe sources § 1 study looked at domestic well testing to monitor water quality § 1 study on cleaning behavior of water storage containers 10 Countries: • Benin, Burundi, Chad, Ethiopia (2), Kenya, Zimbabwe • Bangladesh (3), • Bolivia (3), Nicaragua, USA

Template: The RANAS-Model: Risk, Attitudes, Norms, Ability and Self-regulation HBM TPB PMT HAPA Mosler, H. J. , (2012). A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. International Journal of Environmental Health Research, 22 (5), 431 -449.

Authors Country Safe water option/ Target behavior POU household water treatment Action Confid Planni Costs Other Perso How- ence ng/ Barrie in in Action r s’ s’ nal to-do in Health & Reme Vulner Severi Knowl benefi Feelin Behav Appro Import Knowl Perfor Contin Recov Contr Planni mberi Comm edge ts ior val ance edge mance uation ering ol ng ng ability ty gs itment Altherr et al. 27 Nicaragua SODIS intention and usage Graf et al. 29 Kraemer et al. 34 Kenya SODIS usage Zimbabwe SODIS intention and usage n. a. o + + + o o n. a. o o + + n. a. n. a. o + o n. a. + n. a. o n. a. o + + o + n. a. + o n. a. n. a. + + + n. a. o n. a. o o + + o n. a. o o n. a. o n. a. + + n. a. n. a. Tamas et al. 39 Bolivia SODIS water consumption Heri & Mosler 30 Bolivia SODIS usage Tamas et al. 39 Bolivia consumption of boiled water Sonego & Mosler 37 boiling water for consumption + o o o + + o o + n. a. o o o + n. a. Burundi Lilje et al. 35 Chad consumption of fluoride free water from household filter chlorination of domestic drinking water switching to safe source Huber & Mosler 31 consumption of fluoride free Ethiopia water from community filter Banglades use of arsenic-safe drinking h water options Banglades consumption of arsenic free h deep tubewell water Banglades use of arsenic free shallow h tubewell Huber et al. 39 Ethiopia Inauen et al. 32 Mosler et al. 10 Inauen et al. 33 Stocker & Mosler 36 Flanagan et al. 28 Benin USA R 2 log . 863 log . 245 log . 700. 807. 690. 522 n. a. hygienic handling of water cleaning of water storage container water testing domestic well water testing for arsenic o o + + o o n. a. o o + + + o n. a. + + n. a. o n. a. o o + + + n. a. + o o + + n. a. o n. a. + o n. a. o + + o n. a. o o + n. a. . 568. 688. 590 log . 894 + o log . 679 log . 365 o . 625 . 415

Can psycho-social determinants explain safe water consumption practices? Action Authors Country Safe water option/ Target behavior POU household water treatment Costs Health & Vulner Severi Knowl benefi Feelin edge ts ability ty gs n. a. o + + + o o n. a. o o + + n. a. n. a. o + o n. a. + n. a. o n. a. o + + o + n. a. + o n. a. + + + n. a. o n. a. High. SODIS usage quality of prediction of different safe water consumption o + + o n. a. o o n. a. behaviors: average o. R 2 n. a. value ofo. 637 Bolivia consumption of boiled water n. a. n. a. Altherr et al. 27 Nicaragua SODIS intention and usage Graf et al. 29 Kraemer et al. 34 Confid Planni Other Perso How- ence ng/ Barrie in in Action r s’ s’ nal to-do in Reme Behav Appro Import Knowl Perfor Contin Recov Contr Planni mberi Comm ior val ance edge mance uation ering ol ng ng itment R 2 Kenya SODIS usage Zimbabwe SODIS intention and usage Tamas et al. 39 Bolivia SODIS water consumption Heri & Mosler 30 Bolivia Tamas et al. 39 Sonego & Mosler 37 Burundi boiling water for consumption + o o o + + o o + n. a. o o o + n. a. Lilje et al. 35 Chad consumption of fluoride free water from household filter chlorination of domestic drinking water switching to safe source Huber & Mosler 31 consumption of fluoride free Ethiopia water from community filter Banglades use of arsenic-safe drinking h water options Banglades consumption of arsenic free h deep tubewell water Banglades use of arsenic free shallow h tubewell Huber et al. 39 Ethiopia Inauen et al. 32 Mosler et al. 10 Inauen et al. 33 Stocker & Mosler 36 Flanagan et al. 28 Benin USA o n. a. + + n. a. log . 863 log . 245 log . 700. 807. 690. 522 n. a. hygienic handling of water cleaning of water storage container water testing domestic well water testing for arsenic o o + + o o n. a. o o + + + o n. a. + + n. a. o n. a. o o + + + n. a. + o o + + n. a. o n. a. + o n. a. o + + o n. a. o o + n. a. . 568. 688. 590 log . 894 + o log . 679 log . 365 o . 625 . 415

Determinants which are with great probability useful to be targeted in all contexts Authors Country Safe water option/ Target behavior POU household water treatment Action Confid Planni Costs Other Perso How- ence ng/ Barrie in in Action r s’ s’ nal to-do in Health & Reme Vulner Severi Knowl benefi Feelin Behav Appro Import Knowl Perfor Contin Recov Contr Planni mberi Comm edge ts ior val ance edge mance uation ering ol ng ng ability ty gs itment Altherr et al. 27 Nicaragua SODIS intention and usage Graf et al. 29 Kraemer et al. 34 Kenya SODIS usage Zimbabwe SODIS intention and usage n. a. o + + + o o n. a. o o + + n. a. n. a. o + o n. a. + n. a. o n. a. o + + o + n. a. + o n. a. n. a. + + + n. a. o n. a. o o + + o n. a. o o n. a. o n. a. + + n. a. n. a. Tamas et al. 39 Bolivia SODIS water consumption Heri & Mosler 30 Bolivia SODIS usage Tamas et al. 39 Bolivia consumption of boiled water Sonego & Mosler 37 boiling water for consumption + o o o + + o o + n. a. o o o + n. a. Burundi Lilje et al. 35 Chad consumption of fluoride free water from household filter chlorination of domestic drinking water switching to safe source Huber & Mosler 31 consumption of fluoride free Ethiopia water from community filter Banglades use of arsenic-safe drinking h water options Banglades consumption of arsenic free h deep tubewell water Banglades use of arsenic free shallow h tubewell Huber et al. 39 Ethiopia Inauen et al. 32 Mosler et al. 10 Inauen et al. 33 Stocker & Mosler 36 Flanagan et al. 28 Benin USA R 2 log . 863 log . 245 log . 700. 807. 690. 522 n. a. hygienic handling of water cleaning of water storage container water testing domestic well water testing for arsenic o o + + o o n. a. o o + + + o n. a. + + n. a. o n. a. o o + + + n. a. + o o + + n. a. o n. a. + o n. a. o + + o n. a. o o + n. a. . 568. 688. 590 log . 894 + o log . 679 log . 365 o . 625 . 415

Determinants which may or may not be targeted in all environmental and socio-cultural contexts % Studies N of studies w/w-o effect Behavioral factor determining the difference between doers/non-doers 86% 12/14 Perceived others behavior 80% 12/15 Beliefs about costs and benefits 71% 10/14 Feelings about the behavior 54% 7/13 Confidence in performance 50% 3/6 How-to-do knowledge 38% 5/13 Perceived others’ (dis)approval 33% 2/6 Personal importance 27% 3/11 Health knowledge 25% 3/12 Perceived vulnerability 20% 2/10 Perceived severity

Determinants which are with great probability specific for different populations ü Differences can be observed between countries and project settings even within one country ü E. g. SODIS usage was determined by a different combination of factors for each of the six different studies ü Different combinations of factors explain boiling behaviors in both Burundi and Bolivia. ü Switching to safe water sources was also explained by varying psychological factors between - Ethiopia and Bangladesh - even within Bangladesh Behavioral factors are always specific for populations and countries

Determinants which are specific for different safe water practices Do we find common patterns or systematic differences in the factors identified as relevant for specific target behaviors? No systematic differences in relevant factors from the different types of HWTS options (SODIS vs. boiling vs. filtration vs. chlorination). No systematic differences between relevant factors for HWTS options compared to switching to safer sources or well testing.

Implications for Practice 1. Using psycho-social factors nearly all practices over all studied countries can be explained very well (mean explained variance 64%). 2. Perceived others’ behavior, costs and benefits as well as feelings (e. g. taste) about safe water consumption should nearly always be taken into account in behavior change campaigns. 3. Confidence in performance (self-efficacy), how-to-do knowledge, perceived others’ approval varied more strongly for different target behaviors but also between specific settings and populations and are thus to be evaluated from case to case. 4. The individual’s health risk perceptions played a role in only very few cases. 5. Between countries and between different types of safe water behaviors no systematic differences can be observed. These findings highlight the usefulness of a systematic approach using psycho-social behavioral determinants in order to design effective behavior change strategies.

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