Crossing the Finish Line: Sustaining Behavior Change for the Prevention and Elimination of NTDs

Written By the Neglected Tropical Disease NGO Network WASH Working Group.

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.

Partnerships to achieve WASH and NTD targets

In January 2019, the World Health Organization and the Neglected Tropical Disease NGO Network (NNN) published WASH and Health Working Together: A ‘How-To’ Guide for Neglected Tropical Disease Programmes. Recognising that cross-sectoral collaboration is essential to achieve global targets, the toolkit provides step-by-step guidance for partnerships at all levels, including working with health ministries, the private sector, and local and national WASH agencies, and is adaptable to different needs and local contexts.

The toolkit, which is available online and in print, was developed using real life program experiences and is continuing to be refined and updated by the NNN WASH Working Group to ensure the tools provided respond to the challenges of cross-sector collaboration such as differences in objectives and priorities, and budgetary and capacity constraints.

The road to 2030

To achieve Sustainable Development Goal 3.3 by 2030, WASH investments and interventions must be prioritized in NTD endemic areas. This will require greater understanding of effective behavior change interventions, increased cross-sectoral collaboration between NTDs and WASH actors and the ability to adapt to specific environments.

Cross-sectoral collaboration is required at all levels, from ministries of health and water, down to municipalities. The upcoming WHO NTD 2030 Roadmap, recognizes that meeting its targets is impossible without cross-sectoral collaboration. A new cross-cutting indicator has been added, in which all NTD endemic areas must reach universal WASH access by 2030. The WHO’s 2015-2020 global strategy on WASH and NTDs—which will be updated in line with the NTD 2030 Roadmap— will provide the vision and strategic objectives to ensure that this cross-cutting target is met.

Significant progress towards NTD elimination in recent years has demonstrated what can be achieved when all stakeholders work together in support of our shared vision of a world free of NTDs. It is possible to end the disability, poverty and marginalization faced by the 1.6 billion people affected by NTDs by 2030, but only if all NTD stakeholders work together and support national programs.

•    Angelia Sanders - Co-Chair WASH Working Group, Vice-Chair International Coalition for Trachoma Control, The Carter Center
•    Kelly Bridges - Global Water 2020, NNN WASH Working Group Communications Task Team co-Chair 
•    Sarity Dodson - NNN WASH Working Group Behaviour Change Task Team co-Chair, The Fred Hollows Foundation
•    Tim Jesudason - International Coalition for Trachoma Control, NNN WASH Working Group Communications Task Team co-Chair

All authors are members of the NNN WASH Working Group.