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

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

The objectives of this review are to show whether by using psycho-social determinants safe water consumption practices can be explained sufficiently well 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

We identified a total of 15 studies using health psychology in a quantitative way for explaining safe water consumption behavior Theories encountered: Health Belief Model (HBM) (Rosenstock 1974) Protection Motivation Theory (PMT) (Floyd, Prentice-Dunn & Rogers 2000) Theory of Planned Behavior (TPB) (Fishbein & Ajzen 2010) Health Action Process Approach (HAPA) (Schwarzer 2008) 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 Vulnerability Severity Health Knowledge Costs & benefits Feelings Others’ Behavior Others’ Approval Personal Importance How-to-do Knowledge Confidence in Performance Confidence in Continuation Confidence in Recovering Action Planning/ Action Control Barrier Planning Remembering Commitment R2 POU household water treatment Altherr et al.27 Nicaragua SODIS intention and usage n.a. o + log .863 Graf et al.29 Kenya SODIS usage log .245 Kraemer et al.34 Zimbabwe log .700 Tamas et al.39 Bolivia SODIS water consumption .807 Heri & Mosler30 .690 consumption of boiled water .522 Sonego & Mosler37 Burundi boiling water for consumption Huber et al.39 Ethiopia consumption of fluoride free water from household filter log .679 Lilje et al.35 Chad chlorination of domestic drinking water log .365   switching to safe source Huber & Mosler31 consumption of fluoride free water from community filter .568 Inauen et al.32 Bangladesh use of arsenic-safe drinking water options .688 Mosler et al.10 consumption of arsenic free deep tubewell water .590 Inauen et al.33 use of arsenic free shallow tubewell log .894 hygienic handling of water Stocker & Mosler36 Benin cleaning of water storage container .625 water testing Flanagan et al.28 USA domestic well water testing for arsenic .415

Can psycho-social determinants explain safe water consumption practices? Authors Country Safe water option/ Target behavior Vulnerability Severity Health Knowledge Costs & benefits Feelings Others’ Behavior Others’ Approval Personal Importance How-to-do Knowledge Confidence in Performance Confidence in Continuation Confidence in Recovering Action Planning/ Action Control Barrier Planning Remembering Commitment R2 POU household water treatment Altherr et al.27 Nicaragua SODIS intention and usage n.a. o + log .863 Graf et al.29 Kenya SODIS usage log .245 Kraemer et al.34 Zimbabwe log .700 Tamas et al.39 Bolivia SODIS water consumption .807 Heri & Mosler30 .690 consumption of boiled water .522 Sonego & Mosler37 Burundi boiling water for consumption Huber et al.39 Ethiopia consumption of fluoride free water from household filter log .679 Lilje et al.35 Chad chlorination of domestic drinking water log .365   switching to safe source Huber & Mosler31 consumption of fluoride free water from community filter .568 Inauen et al.32 Bangladesh use of arsenic-safe drinking water options .688 Mosler et al.10 consumption of arsenic free deep tubewell water .590 Inauen et al.33 use of arsenic free shallow tubewell log .894 hygienic handling of water Stocker & Mosler36 Benin cleaning of water storage container .625 water testing Flanagan et al.28 USA domestic well water testing for arsenic .415 High quality of prediction of different safe water consumption behaviors: average R2 value of .637

Determinants which are with great probability useful to be targeted in all contexts Authors Country Safe water option/ Target behavior Vulnerability Severity Health Knowledge Costs & benefits Feelings Others’ Behavior Others’ Approval Personal Importance How-to-do Knowledge Confidence in Performance Confidence in Continuation Confidence in Recovering Action Planning/ Action Control Barrier Planning Remembering Commitment R2 POU household water treatment Altherr et al.27 Nicaragua SODIS intention and usage n.a. o + log .863 Graf et al.29 Kenya SODIS usage log .245 Kraemer et al.34 Zimbabwe log .700 Tamas et al.39 Bolivia SODIS water consumption .807 Heri & Mosler30 .690 consumption of boiled water .522 Sonego & Mosler37 Burundi boiling water for consumption Huber et al.39 Ethiopia consumption of fluoride free water from household filter log .679 Lilje et al.35 Chad chlorination of domestic drinking water log .365   switching to safe source Huber & Mosler31 consumption of fluoride free water from community filter .568 Inauen et al.32 Bangladesh use of arsenic-safe drinking water options .688 Mosler et al.10 consumption of arsenic free deep tubewell water .590 Inauen et al.33 use of arsenic free shallow tubewell log .894 hygienic handling of water Stocker & Mosler36 Benin cleaning of water storage container .625 water testing Flanagan et al.28 USA domestic well water testing for arsenic .415

N of studies w/w-o effect 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

 Behavioral factors are always specific for populations and countries Determinants which are with great probability specific for different populations Differences can be observed between countries and project settings even within one country E.g. SODIS usage was determined by a different combination of factors for each of the six different studies Different combinations of factors explain boiling behaviors in both Burundi and Bolivia. 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 Using psycho-social factors nearly all practices over all studied countries can be explained very well (mean explained variance 64%). 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. 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. The individual’s health risk perceptions played a role in only very few cases. 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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