Environmental health is a critical component of maternal-newborn-child health (MNCH) and overall community health. The Manoff Group's approach to environmental health has been shaped by three decades of work on integrated and innovative solutions to a range of environmental health issues. Honed through experience and a long-standing emphasis on sustainability, our work is noted for four distinct elements:
Best Practices in Behavior Change for Sustainability
Behavior change is critical to achieving program impact and sustainability in environmental health. As a leader in behavior change, The Manoff Group has established guiding principles for how to approach, strategize, implement, monitor, and evaluate behavior change within environmental health programs. Our groundbreaking paper, Behavior First, defined a minimum package of behaviors necessary to achieve effective behavior change in water, sanitation, and hygiene (WASH). This paper established the behavioral continuum for WASH that has become widely used in the field. Behavior First also ensured that attention to optimal practices was included as a key tenet of USAID's Hygiene Improvement Framework.
For behavior change programs to result in sustainable social change, they must respond to the local context. To do this, we have brought our expertise in formative research to environmental health programs. Our formative research methods are accepted best practice, uncovering the motivations behind current and improved practices and the barriers to change. Our methods include Trials of Improved Practices (TIPs), as well as various interviewing techniques designed to elicit needed information from program participants, such as "best friend interviews" for shy respondents.
A Legacy of Innovation
Making a significant and lasting difference in hygiene behavior begins with applying state-of-the-art approaches and tools, but usually requires more—an innovative twist or modification that truly addresses a local perception or technology need. Many of the innovative elements of our programs have come from participants’ suggestions during the formative research. Examples of our innovations—many of which have become standard practice—include:
- Applying commercial marketing techniques to achieve environmental health goals. We were the first to use advertising techniques to “sell” proper handwashing practices in Ecuador in the early 1970s. Later, in Peru, we addressed the need for increased availability of hygiene products by establishing community stores to sell WASH products and generate income for the community.
- Inclusion of unconventional program participants. In the West Bank/Gaza, our activities to reduce diarrhea prevalence and water-borne diseases led us to include an unusual group of participants: water tanker drivers. Our behavior-change strategy included a focus on improving water tanker drivers’ water handling and tanker cleaning practices.
- Behavioral solutions to complement or replace products. In South Africa, where indoor smoke was causing respiratory illness in young children, formative research found that switching fuels or replacing stoves were not feasible options for families. Behavioral trials showed that caregivers could successfully adopt two helpful practices: keeping young children further from smoke and improving ventilation during times of peak emission. Most families were willing to continue practicing these behaviors because they had noticed improvements in their children's health and/or that their house was cleaner.
- Engaging families and communities in monitoring their WASH behavior. In several programs, we developed pictorial tally sheets to help families track their own progress toward achieving their desired hygiene practice, such as moving from washing hands occasionally in a stream to having a handwashing station at home. These sheets are tallied by the community to see where families are positioned on the behavior continuum and determine what kind of support the community can offer.
Promoting Integration to Spread Environmental Health Practices
Effective social change and achieving scale entails leveraging all available channels and networks, including support from municipal and national governments and the private sector. This support becomes more attainable as hygiene and indoor air quality activities are integrated with mainstream MNCH programming, as well as with existing projects in other sectors. The Manoff Group has made a concerted effort to integrate environmental health activities with other development programs, from large-scale community nutrition programming in Honduras and Uganda, to responding to an urgent need to extend the reach of improved hygiene practices to organizations working in home-based care of individuals with HIV/AIDS in Uganda, to school health and nutrition programs in Bangladesh, Malawi, Uganda, and the Dominican Republic.
The critical role of environmental health in MNCH hinges on improving practices and the impact of improved environmental health on health outcomes such as blood lead levels and incidence of diarrhea and pneumonia, leading causes of infant and child mortality. The Manoff Group has long focused on driving the evidence base forward to establish the impact of environmental health on MNCH in operational settings. Several of our activities under USAID’s Environmental Health Project provide such evidence:
- In Zlatna, Romania, we led an activity to address air pollution and lead poisoning. An evaluation one year after implementation found that, based solely on the improved behaviors promoted by our activity, children's blood-lead levels decreased about 25%.
- Our work in Peru shows the progression from improved practices to improved health indicators. In the pilot near Cusco, there was an increase from 46% to 94% in storing drinking water in a covered container, and safe water handling (correct management and use) increased from 36% to 84%. The evaluation showed a highly significant change in diarrhea prevalence (P-value=<.001) for children in the sample: at baseline 22% of the 108 children under five were reported to have had diarrhea within the previous two weeks while at the time of the midterm survey one year later of 114 children, reports of diarrhea fell to 9%.
- In the Dominican Republic, a similar result was reported. Of the 165 children under five years of age included in the baseline sample, 27% were reported to have had diarrhea within the previous two weeks. Five months later, this fell to 11% for the 209 children included in the mid-term survey.