Achieving handwashing with Social Art for Behaviour Change: the experience of the Lazos de Agua programme in Latin America Open Access

Handwashing with soap remains the most simple and powerful hygiene practice to curb the spread of viruses and other infectious diseases that weaken or kill millions of people around the world every year (Prüss-Üstün et al. 2016; World Health Organization 2020). Although the solution seems basic, the alarming reality is that 30% of the world's population lack handwashing facilities with soap and water at home, and that critical settings such as health care facilities (at least 16%) and schools (44%) around the world lack basic handwashing services (WHO and UNICEF 2018, 2019, 2021). As expressed by the Global Handwashing Partnership (2017), ‘behaviour change efforts are critical to ensure handwashing with soap becomes habitual’. Handwashing-promotion efforts that address key identified enablers and barriers have been found to be more effective (Kalam et al. 2021). However, determinants associated with the practice of handwashing with soap are varied and differ depending on the context. Empirical evidence has identified these determinants to include the following among others: the availability of handwashing facilities, access to soap and water, social and cultural norms and broader social and structural factors (White et al. 2020). This suggests that tackling handwashing determinants should involve several actors and factors to be working together, including the actors and factors required for ensuring the continuous delivery of water services which are the subject of many water, sanitation and hygiene (WASH) programmes across low-income settings.

Even when behaviour change efforts are part of WASH programmes, evidence of sustained behavioural uptake is mixed (Hulland et al. 2015; Taylor et al. 2015; De Buck et al. 2017). While some observational studies and numerous impact evaluations using experimental or quasi-experimental designs show significant increases in behavioural outcomes (Biran et al. 2014; Briceño Coville & Martinez 2015; Pickering et al. 2015), others have shown no significant effect of behaviour change efforts on behavioural outcomes compared to control groups (Huda et al. 2012) or have shown an attenuation of desired effects over time (Parker et al. 2006). Inconsistencies in the effectiveness of behaviour change interventions may be rooted in the type of approach used for promoting behaviour change and the understanding and tackling of determinants that influence WASH behaviour change (De Buck et al. 2017). De Buck et al. (2017), identified that effective elements of behaviour promotion include the following: involving the community, psychosocial theory-derived elements and using interpersonal communication with active teaching methods and messaging that is innovative and culturally sensitive. The One Drop Foundation Social Art for Behaviour Change™ (SABC) approach includes these effective elements and has been integrated into a WASH system-strengthening programme, the Lazos de Agua Programme (LAP). Implementation of the LAP goes from 2016 to the end of 2022 and is carried out in Colombia, Guatemala, Mexico, Nicaragua and Paraguay by Plan Colombia, Water For People, Living Water International, WaterAid and Fundación Moisés Bertoni, respectively.

This article presents how handwashing is encouraged through the SABC approach, embedded within a system-strengthening programme. It argues why SABC has the potential to be an effective approach towards sustaining handwashing behaviour based on the progress achieved halfway into the LAP and shares the limitations and learnings of its implementation in five countries in Latin America.

Designing and implementing the LAP involves coordinating and involving multiple actors, including funding agencies (foundations and multilateral development banks); national-level authorities (ministries of water, health, education), service authorities (local governments at various levels), service providers (often voluntary water user committees), civil society (implementing NGOs and artist groups) and users (community members). The LAP follows the One Drop Foundation's A•B•C for Sustainability™ model, a systemic approach to support holistic programme implementation where A stands for Access, B for Behaviour and C for Capital:

• The A (Access) seeks to increase the proportion of the population using at least basic levels of water and sanitation services as defined by the Joint Monitoring Programme (WHO and UNICEF 2021) through the construction and rehabilitation of infrastructure and strengthening the governance, operations and maintenance capacities of water user committees and other entities responsible for providing WASH services.

• The B (Behaviour) seeks to increase the proportion of the population practising desired WASH behaviours through the implementation of the One Drop Foundation Social Art for Behaviour Change™ (SABC). The SABC™ approach integrates psychosocial theory-derived elements from the Transtheoretical Model of Behaviour Change developed by Prochaska & DiClemente (1983) and the Integrated Behavioural Model for WASH (IBM-WASH) developed by Dreibelbis et al. (2013). The latter framework identifies three dimensions that influence WASH behaviours, notably contextual, psychosocial and technological. SABC is a participatory and creative approach undertaken in collaboration with intervention communities to bring about behaviour change. By engaging participants through social art, SABC interventions connect and empower community members, improving their leadership and other interpersonal skills and giving them a sense of ownership and agency over their WASH services.

• The C (Capital) component is intended to develop market-based solutions – including financial products, income-generating activities and other services – to increase the pace of making safe water and sanitation accessible to all.

Each country-based project part of the LAP has its own set of actors and factors that need to be addressed to create a transformative WASH programme. Each project uses a system approach aiming to strengthen the enabling environment that provides support and creates coordination mechanisms between the various actors within the system. The projects collaborate and support various parts of this system to promote long-term and sustainable access to WASH services through an integration of the multiple layers of government, community and value chain actors. Given that key determinants of handwashing with soap are access to water, soap and a handwashing station at home, handwashing promotion in the LAP is married to the promotion of another behaviour: the payment of water tariff by the users, which allows the maintenance of the water supply infrastructure, and thereby sustained access to water for handwashing. Institutional involvement has been instrumental in helping the uptake of both the handwashing and the water tariff payment behaviours.

SABC interventions are designed and implemented by local artists trained on the SABC approach by the One Drop Foundation's country-based implementing partners. Before implementation, formative research reveals the profile of the priority groups who ought to practise the desired WASH behaviour, and the behavioural determinants that influence whether these groups engage or not in the behaviour. This step uses Dreibelbis et al. (2013) IBM-WASH model to acknowledge and investigate behavioural determinants belonging to contextual, psychosocial and technological dimensions that operate on five levels: structural, community, household, individual and habitual.

Once these behavioural determinants have been identified and prioritized, artists start ideating and prototyping SABC interventions, including folklore and art techniques, alongside priority group members from the communities. The resulting SABC interventions are diverse but all have common elements: they are artistic, participatory, based on the cultural and behavioural realities of the intervention communities and aim at encouraging the desired behaviour. Each community hosts multiple interventions including one-time and multi-session interventions. One-time interventions invite the community at large thereby involving numerous participants: for example, theatre shows followed by a facilitated discussion where attendees express a commitment to a concrete solution. One-time interventions are either led by artists, or by community members, who were involved in multi-session interventions. Multi-session interventions are led by artists and involve fewer participants actively involved in an artistic process to co-create: for example, short films, songs, murals or puppet shows. At the end of a multi-session intervention, the participants, referred to as leaders of change, lead a one-time intervention, referred to as a replica, accompanied by artists thereby presenting their creation to the community at large.

While the LAP aims at changing various WASH behaviours, this article will focus on handwashing with soap. To measure the prevalence of handwashing behaviour (as well as other WASH outcomes which are not the subject of this paper), a probabilistically representative sample of households was surveyed in each project, totalling over 1,680 households among four projects, at their respective baseline (2017–2019) and again at midline, 22 months later on average and before the start of the COVID-19 pandemic except for the project in Colombia (see Table 1). The project in Guatemala started before the other four projects and had a different monitoring and evaluation system and is therefore excluded from these results. The endline household survey in late 2022 has yet to occur. The number of households surveyed at baseline or midline ranged from 306 up to 615 depending on the project (see Table 2). In Colombia, Paraguay and Mexico, the sampling design was multi-stage, stratified first and then random. In Nicaragua, households from all communities of intervention were sampled randomly and proportionately to the communities’ population. For all projects, sample sizes were calculated at a 95% confidence level and a 5% margin of error. The household questionnaire used can be found in the Supplementary Material.

Households were considered to practise handwashing if they met all of the following criteria: the enumerator observed a handwashing station (fixed or mobile) within 10 paces of the cooking area or the toilet, that had water and soap available, and the respondent mentioned at least the three handwashing key moments encouraged by the Programme – after defaecating, before eating and before preparing food – when asked: ‘On what occasions do members of your household wash their hands with soap and water?’ without answer options given by the enumerator.

In addition to household surveys, story-based interviews were conducted during the second semester of 2020. Story-based interviews complemented household surveys for measuring handwashing by providing depth and isolating the effect of SABC interventions among other programme efforts which include building infrastructure and capacity building of WASH service providers. A story-based data collection approach called Sprockler, developed by the organization Perspectivity, was used. Within the Sprockler approach, the interview questionnaire uses a unique combination of open-ended and closed-ended special questions aimed at collecting qualitative and quantitative data in the form of stories and statistics. At the core of the questionnaire in the Sprockler approach, the respondent is invited to share a story after which closed-ended questions follow through which the respondent self-interprets the meaning of their story. Chances of misinterpretation are reduced by asking respondents questions about their story which also allows them to own and reflect upon their stories. Sprockler uses special questions such as bipoles or tripoles, which trigger more intuitive and instinctive responses and therefore help the self-interpretation set-up to provide more accurate and nuanced findings. Within the Sprockler approach, the importance of stories and the natural tendency and skill humans have for telling stories is not only acknowledged but embraced. Respondents share their experiences through stories, and by collecting many of such experiences and visualizing responses from close-ended questions, recognition of emerging patterns that tell something about the world surrounding the respondents is enabled (Perspectivity n.d.). Voicing experiences through stories can contribute to decreasing participant bias and is particularly suitable among highly indigenous and other population groups where storytelling and oral forms of knowledge transmission are a common means of communication.

In total, 177 community members across four projects who had participated in SABC interventions were interviewed with the Sprockler approach, ranging between 30 and 63 respondents per project (Table 3). Respondents were sampled using non-probability sampling methods to represent the diversity of SABC participants in terms of gender, age, occupation, type of SABC intervention they participated in and time elapsed since the last SABC intervention they participated in. The interview questionnaire can be found in the Supplementary Material. Two story-based questions were at the core of the questionnaire. The first invited the respondent to share a memory about a moment that happened when they participated in SABC interventions, and the second asked them to share and describe any changes, big or small, that they have noticed in their life or community since participating in SABC interventions.

According to household surveys, the population practising handwashing with soap at three key moments increased from 29 to 44% between baseline and midline for the four projects combined (weighted average), an increase that was observable among them all except for project Nicaragua (Figure 1).

Other responses from interviews referred to building handwashing facilities and using running water:

At the community level, beyond increasing handwashing, the LAP has strengthened the role of artists as mediators of change by bringing together water user committee members and water users to improve their collaboration: this mediation has improved discussions between water users and water user committee members, which gives users more confidence in the committee's actions and contributes to them becoming more assiduous in paying the water service tariff.

A group of 10 women of the village San José de Manantiales, in the state of Guanajuato, Mexico, who initially met through the SABC intervention of a puppet theatre production gained the confidence to have their voices heard and replaced the members of their water user committee by themselves, a role that was previously dominated by men.

At the state level, the community engagement from the initial SABC interventions were enough to convince the Guanajuato State Water Commission (in Spanish Comisión Estatal del Agua de Guanajuato or CEAG) to incorporate elements of the SABC approach as part of their social assistance programmes and engagement with water user committees. In particular, the CEAG has added participatory and artistic methods to the role traditionally played by community engagement officers referred to as ‘water promoters’. Following training and support by the State Water Commission, with technical support from the LAP, these promoters now have new SABC tools and ways of involving communities in the management of water systems.

Finally, at the national level, officials from CONAGUA, the Mexican National Water Commission, supported the State Water Commission's efforts by funding their WASH programmes, including social assistance interventions which included SABC training workshops at the municipal level. Tapping into the collective intelligence, connecting various stakeholders through creative and participatory processes has been appreciated by the CEAG and CONGAGUA organizations and is inspiring them to modify their approaches in other locations. This led to the creation of a ‘Coordination Table’ (mesa operativa) which brings together several actors of the water services provision system to define clear ways on how some elements of the SABC approach can be integrated into the social assistance programmes carried out by CONAGUA at the federal level.

While the SABC approach includes effective elements of behaviour promotion identified by De Buck et al. (2017) and is contributing to an increase in handwashing, it has limitations. The SABC approach cannot address contextual or technological determinants as framed in the IBM-WASH by Dreibelbis et al. (2013). SABC interventions are most apt for addressing psychosocial determinants at the community, household and individual levels such as self-efficacy, social integration, cultural identity and social norms, but are limited in their ability to change infrastructure gaps and broader sector systems weaknesses. These gaps are an argument for embedding this approach within larger WASH system-strengthening approaches that could tackle other determinants. This was done with the LAP, which takes a systemic approach to behaviour change by bringing together actors for ensuring Access, Behaviour and Capital to communities. SABC interventions work within this framework to strengthen ties between stakeholders and to drive uptake of new behaviours through a participatory approach rooted in the local culture. Besides handwashing with soap and water tariff payment, the SABC approach can be tailored to address different WASH behaviours, as relevant in different contexts, such as latrine use in areas where open defaecation is common. For example, other projects co-financed by the One Drop Foundation have addressed handwashing with soap and latrine use with SABC in Mali, Burkina Faso, Malawi and India that could provide learnings to behaviour change efforts in those areas. Since the design of SABC interventions relies on context-specific evidence and local arts, their implementation can be adapted to any region. Through SABC, the acceptability by users of newly developed sanitation systems could be addressed, which could potentially benefit the sustainability of sanitation systems by lifting the score of the social sub-index of the Sanitation Sustainability Index developed by Hashemi (2020).

Burton et al. (2021) argue that in order to better design and evaluate ‘transformative WASH’ programmes, a mixed-methods toolkit utilizing human-centred design practices, and proxy methods such as ‘participatory design’ or ‘behaviour-centred design theory’ should be prioritized in order to overcome a siloed approach in delivering long-term impact. As part of the monitoring and evaluation of the LAP, the use of mixed-methods combining household surveys with story-based inquiry through Sprockler has emerged as a dynamic way to capture important data around participation in SABC interventions, and the uptake of the behaviours. These interactive and relational elements allow opportunities for iteration of programming to better fit the needs of users.

Another challenge in implementing the SABC is that it can be complex for artists to design artistic interventions that also aim to change perceptions around taboo topics, increase confidence in services or products or improve self-efficacy in practising a behaviour. The development of the intervention's prototypes may require substantial external support and time early in the projects affecting their cost-effectiveness. Nonetheless, artists have shared their appreciation when involved in the design process from the beginning instead of responding to isolated tasks. The experience of the LAP proves that through the SABC approach, artists can serve as behaviour change facilitators to accompany WASH projects and trigger behaviour change. Through their deep connection to the local context and their imagination and creativity, artists implementing SABC interventions generate a fun and enabling environment by translating complex and often taboo issues into accessible formats that inspire, activate and sustain change. This further empowers people in communities to take charge of their water and sanitation services, participate in water user committees and add soap to their handwashing routine. Examples such as Guanajuato, Mexico, show that SABC interventions can be used as a platform to drive broader behaviour changes among various actors in the WASH value chain and sector, to train, explore, elaborate, innovate and share their experiences, learnings and insights.

Results obtained until now in the uptake of handwashing with the SABC approach are encouraging, as is the institutionalization of the approach by the Mexican Government at the municipal, state and national levels. In the other LAP programme countries, implementing partners continue to collaborate closely with municipal, state and national governments in order to coordinate and support the continuous delivery of WASH services through strong WASH systems after the end of the programme. An endline household survey is planned for the LAP in the last quarter of 2022 which will provide additional opportunities to examine the factors that support a resilient WASH system and will bring further insights about the sustainability of this systemic programme. This new data will be made available at the end of the project, which could inform the potential of scaling the implementation of SABC interventions to the wider Latin American region.

SABC, as part of a system approach for behaviour change, involves WASH service providers, users and policymakers. It has the potential to be an effective approach for increasing handwashing behaviour. The programme works with relevant sector actors at multiple levels and seeks to modify the factors that influence sustained WASH service delivery and use, through multi-sectoral collaboration and system-strengthening, while keeping community users at the centre of the programme.

Ultimately, this aims to create an enabling environment that addresses the Access, Behaviour and Capital needs of the various users in the system. In Guanajuato, Mexico, the government has adopted elements of the SABC approach to strengthen their pre-existing social assistance programmes with a focus on ensuring that all households pay their monthly water tariffs, an essential behaviour to ensure smooth water service provision which is needed for households to continue handwashing with soap. Mixed-methods evaluation of the programme through household surveys and story-based inquiries support the conclusion that SABC interventions were memorable to participants, even after 6–12 months of their last participation in an intervention, and that the vast majority believed the changes in the communities would be long-lasting. Ongoing monitoring and an endline evaluation of the programme will provide further insights on the sustainability of the outcomes.

The Lazos de Agua programme (LAP) is funded through a multi-stakeholder partnership including the founding partners – the Coca Cola Foundation, the Inter-American Development Bank, FEMSA Foundation and the One Drop Foundation – national and local governments, implementing organizations and communities. The One Drop Foundation is also the LAP's Strategic Implementing Partner, coordinating the programme and providing technical assistance to the implementing organizations in various approaches including Social Art For Behaviour Change, value chain, system-strengthening, integration of the components of the ABC for sustainability model, monitoring, evaluation and learning, and communications. An evaluation was undertaken as part of the LAP, funded by the founding partners, and conducted in countries by monitoring and evaluation staff of the implementing organizations. Funding for writing this article has been provided as part of the ongoing staff salary of the One Drop Foundation, as part of its Knowledge and Innovation Unit.

All relevant data are included in the paper or its Supplementary Information.