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The RANAS Approach to Systematic Behaviour Change

The Risks, Attitudes, Norms, Abilities and Self-regulation (RANAS) approach to systematic behaviour change is an established method for designing and evaluating behavior change strategies that target and change the factors influencing a specific behaviour in a specific population. In brief, it is an easily applied method for measuring behavioural factors, assessing their influence on behaviour, designing tailored strategies that change behaviour, and measuring the effectiveness of these.

Although the RANAS approach takes what seems additional effort and resources, it is worth applying, because it results in behaviour change strategies which (1) are tailored to the population, (2) have been proven to effectively change behaviour under local conditions, (3) save resources due to adapted interventions which increase impact, and (4) provide an evidence base for further interventions and upscaling. Not only is behaviour being changed effectively, but substantial arguments are gained with which to attract support from local government and donors for future projects.

Click on the phases, tools or outputs to expand all the information or download all materials.

Please cite as: Ranas Ltd. (2022). The RANAS approach to systematic behavior change. Methodological Fact Sheet 1. Zürich, Switzerland.

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Summary

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Summary

We first decide how the project design will look like (step 1.1 Define project design); we then define the exact behaviour to be changed and the specific population group to be targeted – we specify who exactly should change which behaviour (step 1.2 Define target behaviours and target audience). Then, we collect information on the behavioural factors that might influence the target behaviour in the specific population, for example by conducting qualitative interviews (step 1.3 Explore relevant psychosocial and contextual factors). Thereby, we gain a first impression of the behavioural factors that potentially determine the target behaviour in the specific population and context. In the following, the potential behavioural factors that we have identified are included in the RANAS model (step 1.4 Complement the RANAS factors); this means adapting and extending the RANAS model to the local context.

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Summary

In the previous phase 1, RanasEXPLORE, we have learned about the different behavioural and contextual factors that form part of the RANAS model for behaviour change. The chapter also discussed the importance of carefully selecting the target behaviour and deciding for a project design that fits your context and resources. It also introduced the different steps to conduct qualitative interviews to explore the behavioural factors potentially steering the target behaviour and finally provided guidance on how to adapt the behavioural factors of the Ranas model to your project context.
In phase 2, RanasMEASURE, we will build on the findings from RanasEXPLORE to develop the tools needed for a quantitative baseline survey and discuss what needs to be considered when planning the survey. The first step 2.1 is to develop a questionnaire measuring the behaviour and the behavioural factors, which have now been adapted to the specific context. The information we gained from RanasEXPLORE will guide the development of the quantitative questionnaire. If required, we develop a protocol of structured observations of the target behaviour. In the second step 2.2, the questionnaire and observations are implemented in a baseline survey. The results of phase 2, RanasMEASURE, are quantitative data on behaviours, behavioural factors, and context for the specific target audience.

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Summary

In phase 2, RanasMEASURE, we discussed the development of a quantitative questionnaire and observation tools based on the findings of phase 1, RanasEXPLORE. In a second step, how to conduct the data collection.
In this phase 3, RanasANALYZE, we will learn how to process the obtained data from the baseline survey and how to determine those behavioural factors that steer the target behaviour. Based on this information, the according behaviour change techniques will be selected and the campaign designed in phase 4.

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Summary

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Summary

So far, we have seen how to prepare a behaviour change project (phase 1, RanasEXPLORE) and how to analyse and understand behaviour. For that, we have done an in-depth qualitative analysis and a quantitative analysis of the situation and the context, the behaviour(s) in question and their influencing factors (phase 2, RanasMEASURE). Based on this and comparing doers with non-doers (phase 3, RanasANALYZE), we chose BCTs to change the most influential factors, thus creating a campaign strategy and manual (phase 4, RanasDESIGN).
In this chapter, we will see how to prepare the implementation of the campaign (step 5.1.: prepare to implement campaign) based on the campaign strategy. With the help of these preparations, the behaviour change campaign will be implemented (Step 5.2: Implement and monitor behaviour change campaign), and we will see how to monitor the campaign implementation (Step 5.2: Implement and monitor behaviour change campaign). The same checklists used for training (step 5.1: Prepare to implement campaign) and implementation (Step 5.2: Implement and monitor behaviour change campaign) will also serve for monitoring and thus quality control. The supervisors record whether each activity is put into practice the way it was planned.

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Summary

In the previous phases, we have seen how to set the parameters of the project (phase 1: RanasEXPLORE), how to analyse the target population’s behaviour, context and behaviour-influencing factors (phase 2: RanasMEASURE and phase 3: RanasANALYSE). The results of the explorative phase and the baseline survey have been used to choose behaviour change techniques and these build the basis for a campaign strategy (phase 4: RanasDESIGN). With the help of the campaign strategy and intervention checklists, the campaign has been implemented and monitored (phase 5: RanasIMPLEMENT).
After having implemented the developed behaviour change campaign, most projects evaluate whether the targeted behavioural factors and behaviours have changed as anticipated. In some projects, a before and after measurement is not possible, in which case this phase does not fully apply. To measure short-term effects, a constant monitoring can be put into place for direct feedback and improvement (phase 5, RanasIMPLEMENT). To measure long-term effects, the follow-up survey should be conducted 6, 12, 18, or even 24 months after campaign implementation. For this evaluation, a follow-up questionnaire has to be developed (step 6.1.), the follow-up survey(s) have to be implemented (step 6.2.) and the data has to be used to quantify the change that has taken place (step 6.3.). Finally, the findings of the evaluation are used to improve the existing campaign, scale it up to a bigger target population and / or to plan future behaviour change campaigns (step 6.4.). Evaluation is important for accountability and learning because it examines the achieved outcomes, the efficiency and the wider impact on people’s lives and allows

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Box 1.2 Examples for questions to key informant interviews

  • How safe is this area?
  • Are there schools in the area?
  • What are the most pressing problems in this area?
  • Are there certain behaviours, that you would like to see changed in the community?
  • Who of the household members is responsible for decision making regarding the target behaviour?
  • What kind of projects are going on in the area about the target behaviours?
  • Is hardware for the behaviour available in the area? (Toilets, sinks, handwashing stations etc.)
  • How often do people perform the target behaviour?
  • How many people regularly perform the target behaviour?
  • Which activities have been implemented?
  • Who realized those activities?

Box 3.1.: Data cleaning 

Before proceeding, we have to check whether the data was correctly entered and, if necessary, correct it. Of course, we cannot check every single value. However, we can check (1) whether there are any missing values, namely empty cells, and (2) whether there are questions with values outside the possible range of response options. The conditional formatting function in Excel is a helpful tool for this. Empty cells or values outside the possible range of response options can be highlighted with this conditional formatting function. Once we identify erroneous values this way, we have to go back to the questionnaire to find the missing or correct values. 

Box 2.1.2 General rules for arranging the questions in a questionnaire

  • Go from general to particular.
  • Go from easy to difficult.
  • Go from factual to abstract.
  • Start with simple demographic questions (e.g. education, main livelihood, age).
  • Start with those questions that might be influenced by other questions, e.g. start with questions about the behavior before asking about Others’ approval of the behavior.
  • Start with closed format questions.
  • Start with questions relevant to the main subject.
  • Do not start with sensitive questions, including sensitive demographic questions (e.g. income).

Box 2.2: Advantages and disadvantages of data collection methods

Advantages Disadvantages
Face-to-face interviews
– Engagement of participant is easier – Highest social desirability bia
– Flexible reaction to participants needs and questions – More time-consuming
No literacy required
– Interview length can flexibly be adapted (max. 60 minutes
Phone-based interviews
– Flexible planning of interviews – No visual interaction with participant
– Flexible reaction to participants needs and questions – Connectivity and reachability of participants
– No literacy required – Potential social desirability bias
– Interview should not exceed 15 minutes
Internet-based interviews
– Less social desirablity bias – No assistance in case of questions or problems
– Time-saving for data collection
– Literacy required
Paper-pencil vs. Electronic data collection
– No electronic devices needed – No data-entry needed
– No dependency on electricity – Data is instantly saved as it was entered into the data collection tool
– Data entry: very time-consuming, high chance of data entry errors

Box 2.1: Comparing RANAS surveys to KAP surveys

Most behaviour change interventions in the water, sanitation, and hygiene (WaSH) sector are preceded and followed by a Knowledge, Attitudes, and Practice (KAP) survey to inform and evaluate the interventions. While there are similarities between KAP surveys and RANAS surveys, they also differ in certain crucial respects.

First, KAP surveys only consider knowledge and attitudes. However, we know from existing scientific evidence that knowledge and attitudes are neither the only nor even the most important determinants of behaviour. Consequently, the RANAS surveys include a much broader range of behavioural factors: (1) risk factors (similar to knowledge); (2) attitude factors (both surveys); (3) norm factors (only RANAS survey); (4) ability factors (only RANAS survey); and (5) self-regulation factors (only RANAS survey).

Second, different KAP surveys do not define knowledge, attitudes, and practice consistently. Therefore, even KAP questions for the same behavior and population vary significantly. In contrast, RANAS behavioural factors and outcomes have been defined precisely (Tool 1e: Definitions of behavioural factors). This allows the consistent formulation of survey questions.

Third, the RANAS approach to systematic behaviour change, where the RANAS survey is part of, allows to identify behaviour change interventions fitting the relevant behavioural factors (see catalogue of Behaviour Change Techniques, BCTs, in chapter 4 “RanasDESIGN”). For KAP surveys, no such tool to develop a corresponding behaviour change intervention exists.

Box 1.12.: Allocation of the identified behavioural and contextual factors to the corresponding RANAS factor

Take the results from the qualitative interview data entry table and check for each question, whether you can identify any reoccurring pattern. For example, are there feelings which are named by several respondents? Which barriers are most frequently mentioned? Of you have conducted focus group discussions, you would already have this summary. Next, consider the following table and write the results next to the RANAS factor they correspond to. If there are results which do not match any of the RANAS factors, write them under “additional factors” at the bottom of the table. The following table contains some example results.

RANAS behavioural factorsCorresponding result from qualitative interviews or focus group discussions (Examples for HW)
Beliefs about Costs and BenefitsHandwashing with soap is time-consuming.
FeelingsFeeling clean after handwashing. Not liking scent of soap.
Others’ BehaviorIt is a family custom to wash hands.
Others’ (Dis)ApprovalHaving been told to do so during childhood.
Barrier PlanningLack of time to integrate handwashing into daily routines.

Box 1.11.: Example of data entry table

Enter each question in a separate row in columns 1 of your table. In the subsequent columns, enter the responses of your respondents. Use a separate column for each respondent.

Questions Behavioural factor Respondent /focus group 1 Respondent / focus group
How do you or others perform… (frequency, timings, place, materials)? Behaviour
What do you dislike about…? Feelings
What do you think are the advantages of …? Benefits
Do you see any barriers/problems to perform …? Tell me about any situations when you do not (or are unable to) perform …? Barrier planning
To whom would you like to listen to what he/she has to say about …? Others disapprova
 

Box1.10. Ethical Issues

Personal privacy:
  • Personal privacy must be respected
  • Enter homes only when invited to enter
  • Conduct interviews in a place without disturbance
Informed consent:
  • Inform participants about the study purpose and procedures in a language understandable to them
  • The participant explicitely agrees with the participation
Voluntary participation:
  • There is no obligation to participate
  • The interviewee is free to not answer some questions
  • The interviewee is free to quit the interview anytime
Confidentiality:
  • The answers are treated confidentially / stay within the group
No promises:
  • No gifts for participation

Box 1.9: Examples for questions used in a qualitative interview

Behavioural FactorQuestions
BehaviourHow do you or others perform… (frequency, timings, place, materials)
FeelingsWhat do you dislike about…?
BenefitsWhat do you think are the advantages of …?
Barrier planningDo you see any barriers/problems to perform …?
Tell me about any situations when you do not (or are unable to) perform …?
Others’ (dis)approvalTo whom would you like to listen to what he/she has to say about …?

Box 1.8.: Conducting individual qualitative interviews

Preparations:
  • Select the participants. They should be part of the target population you have specified in 1.2 (e.g. primary caregivers)
  • Use Tool 1c to prepare the questionnaire guide.
  • Prepare questions on both the target behaviour and the competing, undesired behaviour.
  • Material: Notebook or printed question guide with spaces for responses, pen
  • Staff: One data collector
Introduction and consent:
  • Engage the participant in some easy conversation.
  • Give introductory information about the target behaviour and that you are interested in participants’ opinions regarding advantages, disadvantages, and barriers to the behaviour.
  • Explain that participants help you and the community most by giving answers that truly represent their opinions.
  • Explain that you are interested in participants’ thoughts and opinions and not in any particular answers and that there are no right or wrong answers.
  • Obtain participants’ agreement for conducting and documenting the interview.
  • Note the participant’s age and gender
Procedure:
  • Conduct the interview following the question guide.
  • Try to collect answers to all predefined questions.
  • Ask free additional follow-up questions whenever a topic of particular interest is raised.
  • Try to lead the participants back to your main topic whenever the interview or discussion has strayed away from your main topic.
  • At the end, sum up the main points of the interview or discussion.
  • Close the interview or discussion by thanking the participants for their help and asking whether they have any final comments or questions.
  • Immediately after: finalize the notes.

Box 1.7. Conducting focus group discussions

Preparations:
  • Select the participants. They should be part of the target group you have specified in 1.2 (e.g. primary caregivers)
  • Consider Box 1.4 when selecting participants and decide carefully, who you invite together.
  • In any case schedule separate discussions with doers and non-doers.
  • Use Tool 1c to prepare the questionnaire guide.
  • Prepare questions on both the target behaviour and the competing, undesired behaviour.
  • Material: paper cards, pens, flipchart, tape
  • Staff: One moderator and one note taker.
Introduction and consent:
  • Give introductory information about the target behaviour and that you are interested in the participants’ opinions regarding advantages, disadvantages, and barriers to the behaviour.
  • Explain that participants help you and the community most by giving answers that truly represent their opinions.
  • Explain that you are interested in participants’ thoughts and opinions and not in any particular answers and that there are no right or wrong answers.
  • Obtain participants’ agreement to conducting and documenting the discussion.
  • Make a list of all participants, their age, gender and (if relevant) position (or why they have been included into the FGD.
Procedure
  • The moderator poses the first question from the interview guide, and lets participants write their answers in short expressions (one or a few words) on cards (1 to max. 5 per person).
  • Once every participant is content with the words they wrote, each participant explains each card and hands it to the moderator, who one by one (as they keep arriving) groups the cards by content, e.g. by sticking them to the wall or blackboard.
  • When all cards are grouped, participants discuss the result and if necessary, cards are moved.
  • Each category is then given a headline and a photo is taken. The co-moderator writes down an explanation / resumption of results.
  • Repeat this process for each behavior; if necessary, with a new group of participants.

Box 1.6.: Focus group discussions: Group processes and pressure and how to minimize their influence

Keep in mind that group processes and social pressure can substantially impair focus group discussion outcomes. Distorting influences may be:
  • Past events and existing alliances among participants are likely to replicate in the group discussion and will influence all participants’ behaviours, interactions, and answers.
  • The first topic emerging in a discussion bears the risk that participants stick to it and neglect other relevant topics.
  • Silent participants who do not share their thoughts.
  • Minorities’ opinions may be overheard (especially in larger groups).
  • Status differences that exist between participants in real life may prevail so that some participants are not allowed to speak or do not feel comfortable sharing their thoughts.
  • Dominant participants may be the only ones defining the topics and using most of the discussion time.
  • Leaders and respected people may dominate the discussion.
  • Hidden agendas may make participants presenting biased information that serves their personal interests.
Tips to minimize group processes and social pressure in focus group discussions:
  • Depending on the culture, organize separate meetings for women and men.
  • Depending on the culture, organize separate meetings for different social groups (e.g. people of different status).
  • Try to include all participants in the discussion by explicitly asking specific participants (e.g. silent participants) to share their opinions and thoughts.
  • Ask participants to brainstorm first and if possible, write down or draw their answers. Every participant is then invited to share these points.

Box 1.5. Examples of potential target groups

  • Women/Men
  • Primary caregivers
  • Heads of households
  • Children
  • Pupils
  • Leaders
  • Teachers
  • Mothers/Fathers
  • Most vulnerable (e.g. disabled persons)

Box 1.4. Example descriptions of the behaviour ‘to use a latrine’ and ‘to wash hands with soap’

The behaviour of using a latrine implies the following actions:
  • Walk to the latrine, open the door, and remove the cover (preparatory actions).

  • Defecate, clean the anus (main actions).

  • Cover the latrine, (wash hands), leave the latrine, close the door, walk back (finalizing actions).

The behaviour of handwashing implies the following actions:
  • Walk to handwashing facility (preparatory actions)
  • Wet hands, apply soap, lather and scrub for 20 sec, rinse hands with water for 10 sec, dry hands in the air or with a clean towel (main actions)
  • Walk back (finalizing actions).

Box 1.3.: Examples for spot check question

  • Interviewers observe the following, depending on the target behaviour:
  • Water treatment – solar water disinfection (SODIS)
  • Are there any PET bottles placed outside the house?
  • How many?
  • Where?
  • Are they in the sun?
  • Is the water in the bottles clear?
  • Water container
  • Does the storage container have a cover?
  • If yes: Is it presently fully covered?
  • Open defecation and latrine use
  • Are there any human excreta in the wider surrounding of the house?
  • Is there access to a latrine for defecation?
  • Does the latrine smell (fecal odors)?
  • Are flies present?
  • Handwashing:
  • Where is the hand washing place located?
  • Which water device is present for handwashing?
  • Is water present?

Box 1.1

Examples of behaviours related to safe drinking water consumption:
  • Collecting drinking water mainly (minimum 80%) from a safe source
  • Regular cleaning of transportation containers
  • Safe storage of drinking water at home
  • Regular cleaning of scooping and drinking vessels
  • Point-of-use disinfection (e.g. chlorination, boiling, filtering of drinking water)
  • Exclusive consumption of safe water by all household members
Examples of behaviours related to sanitation:
  • No open defecation
  • Constructing or purchasing toilets
  • Using toilets
  • Improving toilets (e.g. providing a cover or roof)
  • Avoiding inappropriate use
  • Cleaning toilets
  • Emptying or paying for service
Examples of behaviours related to handwashing with soap:
  • Availability of water, soap and handwashing infrastructure
  • Handwashing with soap after contact with faeces (e.g. after defecation, after cleaning child’s bottom, after removing child faeces)
  • Handwashing with soap before handling food (e.g. before eating, before preparing food, before giving food to a child)
Examples of other behaviours related to health and the environment:
  • Hygienic handling and cooking of food
  • Washing the body with water and soap
  • Menstrual hygiene
  • Housing hygiene (e.g. safe storage of cookware)
  • Waste separation: availability of space for separate bins, availability of separate waste treatment
  • Not littering: depositing waste in waste bins, emptying of bins at the official dumping site, taking garbage home when no bins are available

Box 2.2.1: Guideline on data collection scheduling

Of course, this depends on the length of the questionnaire and on whether the survey also involves direct observations or spot checks. However, we can usually schedule using these guideline figures:

  • Duration of one interview: 15-30 minutes – refusals are rare.
  • Duration of one direct handwashing observation: 2–4 hours.
  • Capacity of one data collector per day:
    • 5–8 interviews or
    • 2 direct handwashing observations, each followed by an interview.
  • Capacity of 5 data collectors in one week (6 working days):
    • 150 – 240 interviews or

    •  60 handwashing observations and interviews.

  • Capacity of 10 data collectors in one week (6 working days):
    • 300 – 480 interviews or

    • 120 handwashing observations and interviews.

It is important to bear in mind that during the first few days, before the data collectors are fully familiar with the survey instruments, their capacity is somewhat lower.

 

Picture of BCTs

BCT 1: Present facts

Presenting the F-Diagram with cards for promoting handwashing in Ethiopia

 

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Catalog of behavior change techniques (BCTs

ESI 3.1 to A practical guide using the RANAS approach Version 1.0, August 2016

ESI 3.1: Catalog of behavior change techniques (BCTs)

According to Michie et al. (2013) a BCT is an observable, replicable, and irreducible component of an intervention strategy designed to alter or redirect causal processes that regulate behavior. That means a BCT is an intervention element that cannot be further decomposed, it is the elementary unit of behavior change.

An intervention strategy comprises one or several BCTs and a communication channel with which the BCTs are brought to the recipients. Communication channels should not be confused with BCTs as they are the instruments to deliver the BCTs. Communication channels are the “how” of an intervention strategy whereas the BCTs are the “what”. Several intervention strategies together form a behavior change campaign.

While many of the BCTs address more than one behavioral factor, all but one have a predominant behavioral factor on which they operate (see the main behavioral factor listed in the left-hand column below). The exception is Exploit persuasive attributes, which means using the persuasive attributes of the information/testimonial source and of the message. Persuasive attributes include the competence, sympathy, credibility, famousness, and publicity of the source and the length and number of arguments of the message. As every BCT implies a specific source from which a specific message is sent, Exploit persuasive attributes can be applied in combination with every other BCT so as to increase impact.

As an example, we could exploit the persuasiv attributes of specialists and medical doctors: For promoting the collecting of water from a safe well, at a community meeting at the health center, a water specialist, showing scientific data, tells about the level of contamination found by analyzing the water from the unsafe well. Subsequently, a medical doctor in a white coat explains the consequences of consuming the contaminated water on the human body. Information leaflets issued by a known medical institute are distributed to the audience. Alternatively, we could exploit the persuasive attributes of famous people: For promoting handwashing, a famous actress plays the leading part in a TV spot that promotes handwashing. She reprimands her sister in law for not having washed her hands before preparing food. She explains why this is important and shows how to wash hands correctly with soap and water. In the following, for each factor block a list of BCTs is presented based on Abraham (2012), Michie et al. (2013) and Mosler (2012).

Information BCTs – Risk factors

The block of risk perceptions can be influenced by information techniques, meaning that with the given information the person is able to understand the menacing health threat.

Factor: Health knowledge
Factor: Vulnerability
Factor: Severity
Persuasive BCTs – Attitudinal factors

Beliefs about costs and benefits as well as feelings about (omitting) the behavior can be changed by bringing forward strong arguments, using persuasive attributes or highlighting emotions.

Factor: Beliefs about costs and benefits
Factor: Feelings
Norm BCTs – Normative factors

BCTs targeting norms are provided to change the perceived social pressure resulting from personal beliefs about other people’s behavior and personal beliefs about others’ appreciation of the behavior.

Factor: Others’ behavior
Factor: Others’ (dis)approval
Factor: Personal importance
Infrastructural, skill and ability BCTs – Ability factors

Beliefs about costs and benefits as well as feelings about (omitting) the behavior can be changed by bringing forward strong arguments, using persuasive attributes or highlighting emotions.

Factor: How-to-do knowledge
Factor: Confidence in performance
Factor: Confidence in continuation
Factor: Confidence in recovering
Planning & relapse prevention BCTs – Self-regulation factors

Planning interventions in general help to translate goals into actions by preventing distraction, avoiding falling back into old habits or inhibiting failing to get started. Relapse prevention BCTs can enable persons to foresee highrisk situations in which lapses may happen and to avoid them.

Factor: Action planning
Factor: Action control
Factor: Barrier planning
Factor: Remembering
Factor: Commitment

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RANAS behaviour change techniques (BCTs)

Nadja Contzen and Hans-Joachim Mosler

Behaviour change techniques (BCTs) are the components of an intervention strategy designed to alter or redirect the processes that regulate behaviour. In other words, they change behaviour.

BCTs are observable, replicable, and irreducible, meaning that they cannot be divided into smaller sub-elements. Several BCTs can be combined, and they are brought to recipients through one or several communication channels, thus forming intervention strategies. BCTs are the what of an intervention strategy, whereas the communication channels are the how.

To be most effective, BCTs should correspond with the behavioural factors that were found to differ between doers and non-doers. While many of the BCTs address more than one behavioural factor, all but one have a predominant behavioural factor on which they operate (see the main behavioural factor listed in the left-hand column below). The exception is to exploit persuasive attributes, which means using the persuasive attributes of the information or testimonial source and of the message. Persuasive attributes include the competence, sympathy, credibility, famousness, and publicity of the source and the length and number of arguments of the message. As every BCT implies a specific source from which a specific message is sent, exploiting persuasive attributes can be applied in combination with every other BCT so as to increase impact. Each BCT is briefly described here.

Table: Behavioural factors and corresponding behaviour change techniques
Behavioural factors Behaviour change techniques
Information BCTs – Risk factors
Factual knowledge 1.                  Present facts: present information about the circumstances and possibilities of suffering from a risk and about the relationship between a behaviour and the risk.
2.                  Present scenarios: present situations in the everyday life of the participant, showing how a behaviour leads to suffering damage from a risk.
Vulnerability 3.                  Inform about and assess personal risk: present qualitative and quantitative assessments individually for each person in such a way that the person realizes that she or he is at risk.
Severity 4.                  Arouse fear: use threatening information that stresses the severity of suffering damage from a risk.
Persuasive BCTs – Attitude factors
Beliefs about costs and benefits 5.                  Inform about and assess costs and benefits: provide information about costs and benefits of a behaviour and conduct a cost-benefit analysis. 
6.                  Use subsequent reward: reward the person each time she/he has performed the desired[1] behaviour or achieved the behavioural outcome. 
7.                  Self-Incentive: Prompt to plan to reward oneself in future if there has been effort and progress in performing the desired behaviour.
8.                  Inform about and assess social and environmental consequences: Provide information about social and environmental consequences of performing the desired / undesired behaviour. Prompt imagining and comparing of future outcomes of changed versus unchanged behaviours.
Behavioural factors Behaviour change techniques
Feelings 9.                  Describe feelings about performing and about consequences of the behaviour: present the performance and the consequences of a desired behaviour as pleasant and joyful and its omission or an undesired behaviour as unpleasant and aversive. 
10.              Prompt anticipated regret: bring people to imagine the concerns and regret they would feel after performing the undesired behaviour.
Norm BCTs – Norm factors
Others’ behaviour 11.              Inform about others’ behaviour: point out that a desired behaviour is already adapted by (a majority of) other persons. Increase visibility of others’ desired behaviour displayed through environmental clues.
12.              Prompt to talk to others: invite participants to talk to others about performing the desired behaviour in question.
13.              Prompt public pledging: let people commit to the desired behaviour and make their commitment public, thus showing to others that there are people who perform the behaviour. 
14.              Social comparison: Facilitate observation of others in order to evaluate one’s own performance
Others’ (dis)approval 15.              Inform about others’ approval / disapproval: point out that important others support the desired behaviour or disapprove of the undesired behaviour. 
16.              Prompt to resist social pressure: In case there is social pressure against the desired behaviour, ask participants to anticipate and prepare for negative comments from others or for pressures towards the undesired behaviour.
Personal norms 17.              Provide a positive group identity and use in-group terms: describe people already engaged in the desired behaviour in an attractive way, to increase the attractiveness of the behaviour itself. Use terms which evoke a feeling of belonging to this desirable group.
18.              Prompt identification as role model: ask participants to set a good example (e.g. for children) by engaging in the desired behaviour so as to influence others’ behaviours by one’s own behaviour.
19.              Highlight conflict: Make the conflict between the undesired behaviour and the participant’s personal norms and values visible.
20.              Set normative nudges: Activate participants’ personal norms in the moment of the behavioural decision through symbols of values in the person’s environment.
21.              Highlight alignment: Make the alignment of personal norms with other benefits of the desired behaviour visible.
Infrastructural, skill and ability BCTs – Ability factors
Action knowledge 22.              Demonstrate behavioural options: Inform about behavioural options. Inform the participant about existing alternatives to the undesired behaviour.
23.              Provide instruction: convey know-how in order to improve a person’s knowledge about how to perform the respective behaviour.
Confidence in ability 24.              Demonstrate and model behaviour: demonstrate the desired behaviour and prompt participants to pay attention to others’ performing the behaviour and its consequences in their everyday life.
25.              Prompt guided practice: train participants in behaviour enactment by giving instructions, demonstrating the desired behaviour, and letting him/her practice; and give feedback about the correctness of the performance of the behaviour. 
26.              Prompt behavioural practice: prompt participants to practice the desired behaviour in their daily life.
Behavioural factors Behaviour change techniques
27.              Organize social support: prompt participants to seek practical, informational, or emotional support from others and/or to initiate social support groups. Advise on and arrange social support for performance of the desired behaviour.
28.              Set graded tasks/goals: prompt participants to learn difficult behaviours, including several tasks, step by step. 
Confidence in continuation 29.              Reattribute past successes and failures: prompt participants to attribute failures to a temporary lack of skill or adverse circumstances instead of to his/her deficiency and successes as personal achievements.  30.              Use arguments to bolster self-efficacy: convince participants that they will be able to perform and maintain the desired behaviour.
Confidence in recovering 31.              Prompt coping with relapse: tell participants that lapses are normal when adopting a new behaviour and, though discouraging, not a sign of failure.
Planning & relapse prevention BCTs – Self-regulation factors
Action planning 32.              Prompt specific planning: stimulate participants to formulate when, where, and how she/he plans to execute the behaviour. 
Action control 33.         Prompt (self)-monitoring of behaviour: invite the participant to regularly record the actual behaviour performance (e.g. correctness, frequency and duration). 
34.              Provide feedback on performance: give participants feedback on their behaviour performance.
35.              Highlight discrepancy between set goal and actual behaviour: request the participant to evaluate the actual behaviour performance in relation to the set behavioural goal.
Barrier planning 36.              Prompt coping with barriers: ask participants to identify barriers to behaviour change and plan solutions to those barriers. 
37.              Restructure the social and physical environment: prompt participants to remove social and physical bolsters of the undesired behaviour to interrupt habits.
Remembering 38.              Use memory aids and environmental prompts: prompt participants to install memory aids or to exploit environmental cues so as to help to remember the new behaviour and to trigger it in the right situation. 
Commitment 39.              Prompt goal setting: invite participants to formulate a behavioural goal or intention.
40.              Prompt to agree on a behavioural contract: invite the participant to agree to a behavioural contract to strengthen her/his commitment to a set goal.

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RANAS behaviour factors

Nadja Contzen and Hans-Joachim Mosler

Behavioral factors are perceptions, thoughts, feelings, and beliefs which influence the practice of a behavior. Together, they characterize the mindset of a person with regard to that behavior. Different behavioral factors will most critically regulate different behaviors in different populations and contexts. To select the most effective behavior change techniques, we recommend surveying all the potential behavioral factors and conducting a doer/non-doer analysis to specify which behavioral factors are most critical. These are the factors to be addressed through behavior change techniques. Here, we first define all potential behavioral factors and then present example questions for each factor for chlorinating drinking water.

Table 1: Definitions of behavioural factors
Behavioural factorDefinition
Risk factors: represent a person’s understanding and awareness of the health risk.
Factual knowledgeA person’s knowledge about a disease’s causes and (personal) consequences and its preventive measures or about the (health) impact of environmental issues.
VulnerabilityA person’s estimate about the general probability to contract a disease and the subjective awareness of the personal risk of contraction.
SeverityA person’s assessment of the seriousness of an infection and of the significance of the disease’s consequences.
Attitude factors: represent a person’s positive or negative stance towards a behaviour.
Beliefs about costs and benefitsA person’s beliefs about monetary and non-monetary costs (time, effort etc.) and benefits (lower medical costs, improved health) of a behaviour, including social benefits (higher status, appreciation by others).
FeelingsA person’s emotions (joy, pride, disgust etc.) which arise when thinking of a behaviour or its consequences or when practicing the behaviour.
Norm factors: represent the perceived social pressure towards a behaviour.
Others’ behaviourA person’s observation and awareness of others’ behaviour, his or her perceptions as to which behaviours are typically practiced by others.
Others’ (dis)approvalA person’s perceptions as to which behaviours are typically approved or disapproved by relatives, friends, or neighbours. This includes the awareness of institutional norms, i.e. the dos and don’ts expressed by recognized authorities such as village, tribe, or religious leaders, and other institutions.
Personal importanceA person’s beliefs about what she or he should do or should not do.
Ability factors: represent a person’s confidence in her or his ability to practice a behaviour.
Action knowledgeA person’s knowledge of how to execute the behaviour
Confidence in abilityA person’s perceived ability to organize and execute the courses of action required to practice a behaviour.
Confidence in continuationA person’s perceived ability to continue to practice a behaviour which includes the person’s confidence in being able to deal with barriers that arise.
Confidence in recoveringA person’s perceived ability to recover from setbacks, to continue the behaviour after disruptions.
Self-regulation factors: represent a person’s attempts to plan and self-monitor a behaviour and to manage conflicting goals and distracting cues.
Action planningThe extent of a person’s attempts to plan a behaviour’s execution, including the when, where, and how of the behaviour.
Action controlThe extent of a person’s attempts to self-monitor a behaviour by continuously evaluating and correcting the ongoing behaviour toward a behavioural goal.
Barrier planningThe extent of a person’s attempts to plan to overcome barriers which would impede the behaviour.
RememberingA person’s perceived ease of remembering to practice the new behaviour in key situations.
CommitmentThe obligation a person feels to practice a behaviour.
Table 2: Example questions to measure behavioural factors
Behavioural factor Question example Response scale
Factual knowledge I will present you some potential causes of diarrhoea. Could you please tell me for each whether it is a cause or not? 1.     Water contaminated by bacteria 2.     Mosquito bite 3.     Spicy food 4.     Raw water A = Yes; B = No. Each correct answer is awarded with one point.
Vulnerability How high do you feel is the risk that you contract diarrhoea? 0 = No risk; 1 = A little risk; 2 = A risk; 3 = Quite a risk; 4 = A high risk
Severity Imagine you contracted diarrhoea, how severe would be the impact on your daily life? 0 = Not severe; 1 = A little severe; 2 = Severe; 3 = Quite severe; 4 = Very severe
Beliefs about costs and benefits (effort) How effortful do you think is it to chlorinate all your drinking water? 0 = Not effortful; 1 = A little effortful; 2 = Effortful; 3 = Quite effortful; 4 = Very effortful
Beliefs about costs and benefits (time) How time-consuming do you think is it to chlorinate all your drinking water? 0 = Not time-consuming; 1 = A little time-consuming; 2 = Time-consuming; 3 = Quite time-consuming; 4 = Very time-consuming
Beliefs about costs and benefits (health) How certain are you that chlorinating all your drinking water prevents you from getting diarrhoea? 0 = Not certain; 1 = A little certain; 2 = Certain; 3 = Quite certain; 4 = Very certain
Feelings (behaviour) How much do you like to chlorinate all your drinking water? 0 = Don’t like it; 1 = Like it a little; 2 = Like it; 3 = Quite like it; 4 = Like it a lot
Feelings (taste) How much do you like the taste of chlorinated water? 0 = Don’t like it; 1 = Like it a little; 2 = Like it; 3 = Quite like it; 4 = Like it a lot
Others’ behaviour How many people in your community chlorinate all their drinking water? 0 = (Almost) nobody; 1 = Some of them; 2 = Half of them; 3 = Most of them; 4 = (Almost) all of them
Others’ (dis)approval People who are important to you, how much do they approve to chlorinate all drinking water? 0 = Disapprove a lot; 1 = Disapprove; 2 = Neither approve nor disapprove; 3 = Approve; 4 = Approve a lot
Personal importance How strongly do you feel an obligation to yourself to chlorinate all your drinking water? 0 = Not obliged; 1 = A little obliged; 2 = Obliged; 3 = Quite obliged; 4 = Very obliged
Behavioural factor Question example Response scale
Action knowledge How are 20 Litres of drinking water correctly chlorinated? No answer options are provided. Each mentioned critical step of chlorination is awarded with one point: A = Filter turbid water; B = Add [2 caps] of chlorine to the water; C = Wait for [30] minutes; D = For turbid water, add [two caps] of chlorine to the water. Note: correct amount of chlorine and time depends on used product.
Confidence in ability How confident are you that you can chlorinate your drinking water? 0 = Not confident; 1 = A little confident; 2 = Confident; 3 = Quite confident; 4 = Very confident
Confidence in continuation How confident are you that you can continuously chlorinate all your drinking water even though you have to spend a substantial amount of money on chlorine? 0 = Not confident; 1 = A little confident; 2 = Confident; 3 = Quite confident; 4 = Very confident
Confidence in recovering Imagine you have stopped chlorinating your drinking water for several days, for example because there was no chlorine available. How confident are you that you would start chlorinating all your drinking water again? 0 = Not confident; 1 = A little confident; 2 = Confident; 3 = Quite confident; 4 = Very confident
Action planning Do you have a plan when during the course of your day to chlorinate your drinking water? If yes: Could you please specify the point in time? No answer options are provided. Answers will be classified into “specific plans” (e.g. after breakfast; at 9am) and “unspecific/no plans” (e.g. in the morning).
Action control How much do you pay attention to chlorinating all your drinking water? 0 = Pay no attention; 1 = Pay a little attention; 2 = Pay attention; 3 = Quite pay attention; 4 = Pay much attention
Barrier planning Do you have a plan how you can treat all your drinking water even if there is no chlorine at home? No answer options are provided. Answers will be classified into “correct plan” (e.g. I’ll boil the water) and “incorrect/no plan” (e.g. I’ll drink raw water).
Remembering/ forgetting How often does it happen that you forget to chlorinate your drinking water? 0 = (Almost) never (0%); 1 = Seldom (25%); 2 = Sometimes (50%); 3 = Often (75%); 4 = (Almost) always (100%)
Commitment How important is it for you to chlorinate all your drinking water? 0 = Not important; 1 = A little important; 2 = Important; 3 = Quite important; 4 = Very important

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Doer/non-doer analysis to specify the critical behavioral factors

Nadja Contzen and Hans-Joachim Mosler

Doer/non-doer analysis is a method of identifying the factors that critically steer the target behavior. These have to be tackled by behavior change techniques (BCTs) to induce behavior change. A doer/non-doer analysis compares the responses of people who do a behavior (doers) to the responses of those who do not (non-doers). A large difference between doers and non-doers in responses to a question about a behavioral factor indicates that that factor is critical. A doer/non-doer analysis involves three steps. First, the sample is divided into doers and non-doers. Second, mean scores are calculated separately for doers and non-doers. Third, the mean scores are compared between doers and non-doers. The three steps are explained in more detail here.

Divide the sample into doers and non-doers

For most behaviors, there is no predefined value to divide the sample into doers and non-doers. Instead, a cut-off point has to be determined based on the data. For handwashing, for example, we could decide to categorize only people who fully comply (100% handwashing at key times) as doers and all who wash their hands less than 100% of key times as non-doers. However, such a division might be too strict and unrealistic in many populations. Therefore, a more reasonable cut-off point might be 90% handwashing at key times. In this case, people who wash hands at 90% of key times and more are doers; people who wash hands at less than 90% are non-doers. When we have defined a cut-off point, we divide the sample into doers and non-doers.

Calculate the mean scores of each behavioral factor separately for doers and non-doers

For each behavioral factor (i.e. for each question), the mean score in the responses is calculated separately for doers and non-doers. Below you find a fictional example for the behavioral factors health knowledge and others’ behavior.

Compare the mean scores between doers and non-doers

Next, we compare the mean scores of doers and non-doers for each behavioral factor. We can do this in two ways. Either we can calculate the differences in mean scores between doers and non-doers or we can plot graphs depicting the mean scores of doers and non-doers per behavioral factor. In either case, the critical behavioral factors are those with the largest differences between doers and non-doers. For the example above, the difference between doers and non-doers in health knowledge is 2.46 – 2 = 0.46; the difference in others’ behavior is 3.00 – 1.46 = 1.54. As the difference in mean scores between doers and non-doers is larger for others’ behavior (1.54) than for health knowledge (0.46), others’ behavior is more critical. We draw the same conclusion when depicting the differences between doers and non-doers through a graph (see Figure). Therefore, others’ behavior should be targeted through BCTs.

Figure: Graph comparing doers and non-doers.

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The RANAS model of behavior change

Nadja Contzen and Hans-Joachim Mosler

The core of the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) approach forms the RANAS model (see figure). The model has four components: Behavioural factors that are grouped into five blocks, behaviour change techniques (BCTs) that correspond to the factor blocks, behavioural outcomes, and contextual factors. This Fact Sheet outlines the factor blocks, the corresponding BCTs, the behavioural outcomes, and the contextual factors. More detailed descriptions of the behavioural factors and the BCTs are presented in Method Fact Sheets 3 and 4.

Behavioral factor blocks and BCTs

The first block comprises the risk factors, which represent a person’s understanding and awareness of the health risk. Information BCTs, such as the presentation of facts or risk information, can be applied to target them. Attitude factors appear in the second block. They are a person’s positive or negative stance towards a behaviour and can be addressed through persuasive BCTs. Norm factors form the third block; they represent the perceived social pressure towards a behaviour and are targeted through norm BCTs. The ability factors form the fourth block. They represent a person’s confidence in her or his ability to practice a behaviour and are targeted through infrastructural, skill, and ability BCTs. Self-regulation factors form the last block. They represent a person’s attempts to plan and self-monitor a behaviour and to manage conflicting goals and distracting cues. Planning and relapse prevention BCTs can be applied to change them.

Figure: The RANAS model of behavior change
Behavioral outcomes

All the behavioural factors together determine the behavioural outcomes. The RANAS model considers three behavioural outcomes: behaviour, intention, and habit. Behaviour refers to the execution of actions. It can be use or implementation, e.g. separation of waste.  Both the desired behaviour and competing behaviours must be considered – for example, not only drinking safe water (Behaviour A) but also drinking untreated water (Behaviour B). Intention represents a person’s readiness to practice a behaviour: how willing the person is to execute something. Habits are routinized behaviours that are executed in specific, repeating situations nearly automatically and without any cognitive effort. The table below shows some example questions to measure the behavioural outcomes.

Contextual factors

Behaviour and the behavioural factors that influence it are embedded in contextual factors. According to the RANAS model, the contextual factors can influence behaviour in three ways. First, they may alter the BCTs’ influence on behavioural factors. For instance, an information BCT, providing detailed medical information on
infectious diseases and the necessity of handwashing, may increase health knowledge and perceived vulnerability for a highly educated person but be ineffective for an illiterate person or a child who is overchallenged by the used technical terms and complex interrelations. Second, they can affect behaviour by changing the behavioural factors. For example, a person with low income might perceive organic food to be very expensive while a person with high income perceives it as cheap. Third, they may alter the behavioural factors’ influence on behaviour; for instance, a person might be strongly committed to using public transport, but the commitment may not translate into behaviour due to a bad bus connection to their workplace. The contextual factors can be divided into three categories: the social, the physical, and the personal. The social context is constituted by culture and social relations, laws and policies, economic conditions, and the information environment. The physical context consists of the natural and built environment. Finally, the personal context is formed by socio-demographic factors such as age, sex, and education and by the physical and mental health of the person.

Table: Example questions to measure behavioral outcomes

Behavioral outcome

Example question

Response scale

Behavior (frequency)

How much of your household’s organic waste do you compost?

0 = Almost none; 1 = Less than half;
2 = About half; 3 = More than half; 4 = Almost all

Intention

How strongly do you intend to compost your organic waste?

0 = Not strongly; 1 = A little strongly;
2 = Strongly; 3 = Quite strongly; 4 = Very strongly

Habit (automaticity)

How much do you feel that you compost your organic waste automatically?

0 = Not automatically; 1 = A little automatically; 2 = Automatically;
3 = Quite automatically;
4 = Very automatically

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The RANAS approach to systematic behaviour change

Nadja Contzen and Hans-Joachim Mosler

All behavior is based on processes in people’s minds. Knowledge is activated, beliefs and emotions rise to the fore, and an intention to perform a particular behavior emerges, eventually resulting in observable behavior. In other words, these processes, which we term behavioral factors, determine behavior. To change behavior effectively, these behavioral factors have to be targeted by intervention programs. The Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) approach to systematic behavior change is an established method for designing and evaluating behavior change strategies that target and change the behavioral factors of a specific behavior in a specific population. In brief, it is an easily applied method for measuring behavioral factors, assessing their influence on behavior, designing tailored strategies that change behavior and measuring the effectiveness of these.

Although it was originally developed to change behavior in the Water, Sanitation and Hygiene (WaSH) sector in developing countries, it is applicable to a range of behaviors in various settings and populations. The RANAS approach to systematic behavior change involves four phases (see figure): First, identify possible behavioral factors; second, measure the behavioral factors identified and determine those steering the behavior; third, select corresponding behavior change techniques (BCTs) and develop appropriate behavior change strategies; and fourth, implement and evaluate the behavior change strategies. In the following we briefly describe these four phases.

Figure: The four phases of the RANAS approach to systematic behavior change.

First, the exact behavior to be changed and the specific population group to be targeted are defined; we specify who exactly should change which behavior. Then, we collect information on behavioral and contextual factors that might influence the target behavior, for example by conducting short qualitative interviews with various stakeholders at different levels, including the target population.

Following this, the potential behavioral and contextual factors that we have identified are arranged in the RANAS model of behavior change, which may involve adapting and extending the model. The RANAS model integrates leading theories of behavior change and findings of environmental and health psychology and thus uses scientific expertise built on decades of research. By using the RANAS model to classify and organize the potential behavioral and context factors, we ensure that no important behavioral factors are neglected. For more information about the RANAS model, see Methodological Fact Sheet 2.

First, we develop a questionnaire to measure the behavior and the potential behavioral factors and a protocol to conduct observations of the target behavior. Template tools have been designed for both questionnaires and observation protocols, and these have to be adapted to the local conditions. A doer/non-doer analysis is conducted to identify the behavioral factors steering the target behavior.

This means that the responses of people who perform the behavior (doers) are compared to the responses of those who do not (non-doers); a large difference in the responses between doers and non-doers shows that the behavioral factor in question critically steers the behavior and thus can be addressed through behavior change techniques (BCTs) to change the behavior.

The BCTs that are thought to change the critical behavioral factors specified in step 2 are selected for application in the behavior change strategies. A catalog of BCTs has been compiled to achieve this. The catalog lists which BCTs are thought to change which behavioral factor, based on evidence from environmental and health psychology. The BCTs have to be adapted to the local context and combined with suitable communication channels, which constitute the mode of delivery of the BCTs. Together, the BCTs and the communication channels form a behavior change strategy.

To verify the efficacy of these behavior change strategies and to optimize them, the strategies are evaluated with a before-after control (BAC) trial. This means that the behavior and the behavioral factors are measured with a questionnaire and with observations both before (step 2) and after implementing the strategies. Further, a control group has to be evaluated. This is to control for intervention-independent changes in behavior.

The differences in behavior scores and in behavioral factor scores before and after the strategies’ implementation are calculated and compared to those of the control group. The behavior change strategies have been effective when the before-after differences in behavior and behavioral factors are larger for the population that received the strategies than for the control group. The strategies can be refined if needed. Otherwise, they can be applied directly at larger scales or in other, similar areas, backed up by the evidence that they are effective in changing behavior.

Conclusion

Although the RANAS approach takes several months, it is worth applying; it results in behavior change strategies which (1) are tailored to the population, (2) have been proven to effectively change behavior under local conditions, and (3) thus provide an evidence base for further interventions. Not only has behavior been changed effectively but substantial arguments have been gained with which to attract support from local government and donors for future projects.

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The RANAS approach to systematic behaviour change

Nadja Contzen and Hans-Joachim Mosler

All behaviour is based on processes in people’s minds. Knowledge is activated, beliefs and emotions rise to the fore, and an intention to perform a particular behaviour emerges, eventually resulting in observable behaviour. In other words, these processes, which we term behavioural factors, determine behaviour. To change behaviour effectively, these behavioural factors have to be targeted by intervention programs.

The Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) approach to systematic behaviour change is an established method for designing and evaluating behaviour change strategies that target and change the behavioural factors of a specific behaviour in a specific population. In brief, it is an easily applied method for exploring and measuring behavioural factors, assessing their influence on behaviour, designing tailored strategies that change behaviour and measuring the effectiveness of these.

Although it was originally developed to change behaviour in the Water, Sanitation and Hygiene (WaSH) sector in developing countries, it is applicable to a range of behaviours in various settings and populations.

The RANAS approach to systematic behaviour change involves six phases (see figure): First, specify behaviours, factors and context; second, collect data on behaviours, factors and context; third, conduct Doer/Non-doer analysis; fourth, develop behaviour change campaign; fifth, realize behaviour change campaign and sixth, quantify change in behaviours and factors. In the following, we briefly describe these six phases.

Figure: The four phases of the RANAS approach to systematic behavior change.

First, the exact behaviours to be changed and the specific population group to be targeted are defined; we specify who exactly should change which behaviour. Then, we collect information on behavioural and contextual factors that might influence the target behaviour, for example by conducting short qualitative interviews or focus groups discussions with various stakeholders at different levels, including the target population. Following this, the potential behavioural and contextual factors that we have specified are used to adapt and extend the RANAS model of behaviour change. The RANAS model integrates leading theories of behaviour change and findings of environmental and health psychology and thus uses scientific expertise built on decades of research. By using it to classify and organize the potential behavioural and context factors, we ensure that no important factors are neglected. For more information about the RANAS model, see Method Fact Sheet 2.

First, we develop a quantitative questionnaire to measure the behaviour and the specified behavioural factors and a protocol to conduct observations of the target behaviour. Template tools have been designed for both questionnaires and observation protocols. These have to be adapted to the local conditions, see Phase 1.

A Doer/Non-Doer analysis is conducted to identify the behavioural factors steering the target behaviour. This means that the responses of people who perform the behaviour (doers) are compared to the responses of those who do not (non-doers); a large difference in the responses between doers and non-doers shows that the behavioural factor in question critically steers the behaviour and thus can be addressed through behaviour change techniques (BCTs) to change the behaviour.

The BCTs that are thought to change the critical behavioural factors specified in step 2 are selected for application in the behaviour change strategies. A catalogue of BCTs (see method fact sheet 4) has been compiled to achieve this. It lists which BCTs are thought to change which behavioural factor, based on evidence from environmental and health psychology. The BCTs have to be adapted to the local context and combined with suitable communication channels, which constitute the mode of delivery of the BCTs. Together, the BCTs and the communication channels form a behaviour change campaign strategy.

The developed behaviour change campaign strategy is realized by first training all implementers involved and making sure the interventions are executed the way they have been developed and planned. Detailed checklists that display the steps of the behaviour change campaign strategy will be used for implementation, monitoring and continued improvement.

To verify the efficacy of these behaviour change strategies and to optimize them, the strategies are evaluated with a before-after control (BAC) trial whenever possible. This means that the behaviour and the behavioural factors are measured with a questionnaire and with observations both before (step 2) and after implementing the strategies. Further, a control or comparison group should be evaluated. This is to control for intervention-independent changes in behaviour. The differences in behaviour scores and in behavioural factor scores before and after the strategies’ implementation are calculated and compared to those of the comparison group. The behaviour change strategies have been effective when the before-after differences in behaviour and behavioural factors are larger for the population that received the strategies than for the comparison group. The strategies can be refined if needed. Otherwise, they can be applied directly at larger scales or in other, similar areas, backed up by the evidence that they are effective in changing behaviour.

Conclusion

Although the RANAS approach takes what seems additional effort and resources, it is worth applying, because it results in behaviour change strategies which (1) are tailored to the population, (2) have been proven to effectively change behaviour under local conditions, (3) save resources due to adapted interventions which increase impact, and (4) provide an evidence base for further interventions and upscaling. Not only is behaviour being changed effectively, but substantial arguments are gained with which to attract support from local government and donors for future projects.

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Glossary

Risk, attitudes, norms, abilities, self-regulation (usually refers to the RANAS model)

Several behaviour change techniques paired with communication channels that are appropriate for the context and accessible to the implementing organization

Environmental and health psychology capitalizes on more than 50 years of empirical psychology, the science of mind and behaviour. Environmental and health psychology in particular investigate techniques by which behaviour can be changed. Environmental psychology deals with the interaction between people and the environment and works on such topics as how to encourage people to keep their environment clean, to save energy, or to preserve nature. Health psychology is about how to induce a healthier lifestyle, for example, to quit smoking, to lose weight, to eat healthy, or to do more sport. In short, environmental and health psychologists have gathered an enormous amount of studies about how these behaviours can be influenced. Therefore, the RANAS approach presented in this guideline relies substantially and systematically on findings and theories from environmental and health psychology.

BCT

Behaviour change technique: component of an intervention that influences certain behavioural factor(s).

BCTs are observable, replicable, and irreducible, meaning that they cannot be divided into smaller elements.

A questionnaire to be filled in or answered by a target population.

A range of questions asked in a systematic way with the responses being recorded.  

A technique that uses mathematical and statistical modelling, measurement, and research to understand behaviour with the help of numerical values. Often used to understand the “how”.

A type of analysis that is based on non-numeric information. Often used to understand why.

Psychosocial factors are the behavioural factors of the RANAS model. Psycho-social indicates that these factors are within people's minds (psyche) and in their social environment.

Neighbourhoods, villages, schools or health centres which are part of the RANAS project.

Somebody delivering behaviour change strategies.

Person who does not perform the desired behaviour.

Monitoring is a continuing function that uses systematic collection of data on specific indicators to provide the management and the main stakeholders of an ongoing intervention with indications of the extent of achievement of objectives and progress in the use of allocated funds.

A set of BCTs chosen depending on the results of the doer/non-doer analysis, with messages and activities adapted accordingly to behaviour, analysis results and context.

A visit to someone’s home by a promoter who communicates intentionally with the aim of changing behaviour.  

Person who performs a desired behaviour. 

An excel form or document of a statistical programme like SPSS which displays the answers to the questions from a questionnaire, in written (for qualitative surveys) or numerical (for quantitative surveys) form, for each participant of the survey.  

A person trained in applying a data collection tool like a questionnaire or observation form, often an interviewer  

A group of people who are interviewed at baseline and follow-up and who do not receive the RANAS campaign but a different campaign. This allows to quantify the effects of the RANAS campaign as compared to the other campaign. The comparison group received the RANAS campaign after the follow-up. 

A set of BCTs chosen depending on the results of the doer/non-doer analysis, with messages and activities adapted accordingly to behaviour, analysis results and context. 

Phase 3: RanasANALYZE

Conduct Doer/Non-Doer analysis 

Introduction 

In phase 2, RanasMEASURE, we discussed the development of a quantitative questionnaire and observation tools based on the findings of phase 1, RanasEXPLORE. In a second step, how to conduct the data collection.  

In this phase 3, RanasANALYZE, we will learn how to process the obtained data from the baseline survey and how to determine those behavioural factors that steer the target behaviour. Based on this information, the according behaviour change techniques will be selected and the campaign designed in phase 4.  

 

The steps of this phase are: 

3.1. Prepare the dataset for analysis 

3.2. Defining differences between Doers and Non-Doers (The Doer/Non-Doer analysis) 

Introduction 

For preparing the dataset, the data gathered in the survey is entered into a data file, cleaned, and processed.  

Key actions 

Clean and process collected data 

After data collection, the dataset needs to be prepared for data analysis. In case of electronic data collection, the dataset can be downloaded and imported into Excel. When all data is imported, we have to process it. Cleaning the data is the first step. Missing or erroneous values need to be identified and corrected (see Box 3.1. Data cleaning for details). To further process the data, we need to identify the behaviour-question which can be used to determine doers and non-doers, code open answers into categories and recode multiple answer options into yes/no answers to each answer option (see Box 3.2. Data entry and division of the sample into doers and non-doers for a visual explanation using an example data set). Finally, data entry needs to be done by hand in case data is collected by paper-pencil. In an excel table, each row represents one participant, each column is one question, and each cell thus equals the response of one person to one question (see Box 3.3. Data entry for data collected by paper-pencil for more details).  

Delete personal information 

In order to keep the interview data anonymous, we need to delete any personal data from the data file. If you have not done so already, assign every respondent one ID number. Then copy the ID number together with any personal information on the individual (name, phone number, nicknames) to an extra file. Delete the personal information from the datafile. Only selected individuals should have access to the file containing ID number and personal information. 

Combining responses for data analysis 

Sometimes, it is necessary to combine the responses to some questions or to some question-parts before analyzing the data, thus building scales.  

  • Calculating the mean value of the responses to all questions measuring self-reported handwashing at different key times for each participant gives a self-reported handwashing score. 
  • To sum the responses to the questions on health knowledge for each participant creates a health knowledge score. 

Introduction 

After having prepared the dataset, we conduct a doer/non-doer analysis. A doer/non-doer analysis compares the responses of people who do a behaviour (doers) to the responses of those who do not (non-doers). A large difference between doers and non-doers in responses to a question about a behavioural factor indicates that this factor is critical, meaning that it steers the target behaviour. Small or no differences mean that these factors are not relevant for the behaviour in question, thus no resources need to be spent to address them. A doer/non-doer analysis involves three steps. First, the sample is divided into doers and non-doers. Second, mean scores are calculated separately for doers and non-doers. Third, the mean scores are compared. Following, these three steps are explained in more detail. 

Key actions 

Select questionnaire items for the definition of doers and non-doers of the target behaviour 

There are different possibilities to decide which participants classify as doers and which as non-doers. This decision can either be made based on questions related to the target behaviour (e.g., The last time you defecated; did you use a toilet, or did you defecate in the open?) or questions that are part of the observation protocol (e.g., does the toilet look used?). In case the target behaviour is not yet performed by the target audience, it is also possible to use the intention to perform the target behaviour as the item to classify doers and non-doers (i.e., intenders and non-intenders). For example: In a community, where no toilets exist and people practice open defecation, no doers exist. Therefore, it is possible to use the intention to use a toilet instead of the actual behaviour “toilet use”. Each of these mentioned options has different advantages and disadvantages in terms of social desirability, bias, variance and reliability (see Box 3.4. Advantages and disadvantages of items for the definition of doers and non-doers for a more complete list). 

Divide the sample into doers and non-doers of the target behaviour 

If the behaviour was assessed by a dual response question the distinction of doers and non-doers is simple. For example, the question: The last time you defecated, did you use a toilet, or did you defecate in the open? leads to one group which used a toilet (doers) and a second group which defecated in the open (non-doers). However, for most behaviours, there is no predefined value or cut-off point at which to divide the sample into doers and non-doers. Instead, a cut-off point has to be determined based on the data. For this decision the following rules of thumb are proposed: 

  • The first choice is to define people as doers that perform the behaviour in 100% of the occasions. For avoiding arsenic contaminated drinking water, for example, only people classify as doers that collect 100% of their drinking water from safe water sources. People who consume less than 100% arsenic-free water are considered non-doers.  
  • However, for sound data analysis, none of the two groups of doers and non-doers should contain less than 30% of the sample or less than 30 cases. If classifying doers as people performing the target behaviour in 100% of the occasions leads to less than 30% doers (or less than 30 cases), we need to decide for a more meaningful cut-off point. 
  • For handwashing, for example, we can also decide to categorize only people who wash their hands at 100% of key events as doers, and all who wash their hands less than 100% as non-doers. However, 100% handwashing might be an unrealistic cut-off point for many populations. Therefore, a more reasonable cut-off point might be 90% handwashing prior to and after key events. In this case, people who wash hands at 90% of key events and more are doers; people who wash hands at less than 90% are non-doers.  

 

When we have defined a cut-off point, we divide the sample into doers and non-doers. In most cases, we divide the sample into doers and non-doers based on one measure; however, it is also possible to combine several measures. 

Sort the dataset according to doers and non-doers: 

Sort your data according to your main behavioural outcome variable (column B1, Behaviour: Chlorination, measured in % of household’s chlorinated water). In more detail, the following steps need to be performed: 

  • Select the whole table; selecting your data only partially will distort your data dramatically as only some columns will get sorted and others remain (!), make sure to choose the option “expand the selection” if requested. 
  • Make sure you have selected the option “my data has headers” within the sort command; so that your variable names will always remain in the first row 
  • Now sort your data according to the item that you will use to divide doers and non-doers; this could be a binomial (yes/no) or a linear measure (how much?) 

For formatting cells, using colours under “cell styles” or use the “conditional formatting” options to highlight your groups. Example 3.A. Doer/non-doer analysis example for chlorinating drinking water shows visually, and in more detail how to perform this step.  

Calculate the mean scores of each behavioural factor separately for doers and non-doers 

For each behavioural factor (i.e. for each question), the mean score in the responses is calculated separately for doers and non-doers. Calculation and interpretation of mean scores is quite straightforward for questions with rating scales or about factors such as age; it simply means the average of responses. For yes/no questions, the mean score equals the percentage of yes responses and should be displayed in Excel as a percentage. For open multiple-response questions, we treat every response option as a separate yes/no question; ‘yes’ means that that response was mentioned and ‘no’ means that that response was not mentioned. Example 3.A. Doer/non-doer analysis example for chlorinating drinking water provides more details and visuals on how to calculate means for doers and non-doers. 

Compare the mean scores between doers and non-doers to identify the behaviour-steering factors 

Next, we compare the mean scores of doers and non-doers for each behavioural factor. We calculate the differences between mean scores for doers and non-doers by subtracting the means of the non-doers from the means of the doers. The critical behavioural factors are those with the largest differences between doers and non-doers. These are thus selected to be targeted with the respective BCTs. Please see Example 3.A. Doer/non-doer analysis example for chlorinating drinking water for more details on how to compare the mean scores between doers and non-doers for different kinds of question formats. The following Box 3.5.: Interpretation of results demonstrates how to use the comparison results for interpretation and campaign planning. 

Key resources and information 

  • Data as collected during phase 2 RanasMEASURE 
  • Skilled and trained data entry personnel. 
  • Skilled and trained data analysis personnel. 

 

Outputs 

The behavioural factors steering the target behaviour are determined. These are the factors that we want to tackle through our campaign.  

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Phase 2: Collect data on behaviours, factors and context

First, we develop a quantitative questionnaire to measure the behaviour and the specified behavioural factors and a protocol to conduct observations of the target behaviour. Template tools have been designed for both questionnaires and observation protocols. These have to be adapted to the local conditions, see Phase 1

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Phase 3:  Outputs

Example 3A : Doer/non-doer analysis example for chlorinating drinking water

Figure 1: Data entry and division of the sample into doers and non-doers

Sort the dataset according to doers and non-doers:

Sort your data according to your main behavioral outcome variable (column B1, Behavior: Chlorination, measured in % of household’s chlorinated water). In more detail, the following steps need to be performed:

  • Select the whole table; selecting your data only partially will distort your data dramatically as only some columns will get sorted and others remain (!), make sure to choose the option “expand the selection” if requested.
  • Make sure you have selected the option “my data has headers” within the sort command; so that your variable names will always remain in the first row
  • Now sort your data according to the item that you will use to divide doers and non-doers; this could be a binomial (yes/no) or a linear measure (how much?)

For formatting cells, using colors under “cell styles” or use the “conditional formatting” options to highlight your groups.

Figure 2: Dataset after sorting according to the behavior measure, color coding for doers and non-doers

Calculate the mean scores of each behavioral factor separately for doers and non-doers

For each behavioral factor (i.e. for each question), the mean score in the responses is calculated separately for doers and non-doers. Figure 2 provides a fictional example for three psychosocial factors (Health knowledge, Others’ behavior, and Action control), one open multiple-response question on the reasons for chlorinating drinking water, and two contextual factors (age and monthly income of the household).

Calculation and interpretation of mean scores is quite straightforward for questions with rating scales or about factors such as age; it simply means the average of responses. For yes/no questions, the mean score equals the percentage of yes responses and should be displayed in Excel as a percentage. For open multiple-response questions, we treat every response option as a separate yes/no question; ‘yes’ means that that response was mentioned and ‘no’ means that that response was not mentioned. See figure 1 and 2 for the data entry of open multiple-response questions and figure 3 and 4 for the calculation of mean scores for open multiple-response questions.

More details: calculating means for doers and non-doers is done with the following steps:

  • Separate your two groups of Doers/NonDoers according to the cutoff value (yes vs. no; or a specific value that distinguishes Doers from Non-Doers for you) by inserting several extra rows between the two groups so that the data of one group lies above and the other group below that row. In this example, the cut-off point is 90%: households who chlorinate 90% or more of their drinking water are considered doers, and households who chlorinate less than 90% of their drinking water are considered non-doers.
  • Calculate means for both groups separately for comparison using the arithmetic “MEAN” function
  • Select one cell below the data in one variable and one of your groups
  • Type “=AVERAGE(first cell:last cell)” into that cell or use the built-in function builder to do that – this should calculate the mean value of the range of cell specified
  • You can now do this for all variables and both groups, or simply copy and paste the first AVERAGE cell you created into the other cells where you need the means – this will automatically update the specified cell range to that column and range
  • Compare the mean scores between doers and non-doers to identify the behavior-steering factors

Next, we compare the mean scores of doers and non-doers for each behavioral factor. We calculate the differences between mean scores for doers and non-doers. The critical behavioral factors are those with the largest differences between doers and non-doers. Figure 3 and 4 provide an example of how to do so.

More details: Calculate differences between the means of the two groups in each variable:

  • On a new sheet, create three rows. One with Doers, one with Non-Doers and one which is named Difference between doers and non-doers. Copy-paste the mean scores from the first sheet together with the item names for doers and for non-doers. When pasting values make sure to use the option “paste values only”.
  • In the last row in figure 4 (marked in yellow), under the first variable, create the difference of the mean value of the doers minus the mean value of the non-doers. Repeat this, or copy-paste this cell for the rest of the variables.

Figure 3: Dataset after deviding doers and non-doers

Figure 4: Mean scores for doers and non-doers

For open multiple-response questions, we have to compare each response option between doers and non-doers. When a question has many response options, this involves a great deal of effort, and one can quickly lose track of the comparisons. Therefore, we recommend measuring as many factors as possible by closed questions with rating scales (see Step 2.1).

In Figure 4, the difference in psychosocial factors between doers and non-doers is smallest in Health knowledge (0.10), larger in Action control (1.40), and largest in Perceived others’ behavior (1.50). This means that Others’ behavior is most critical, followed by Action control. When we examine the reasons mentioned for chlorinating drinking water, there is a large difference (40%) in reason 3, to be a good mother, which is much more frequently mentioned by doers than by non-doers, and no difference in reason 4, because chlorination is cheap (0% difference). Therefore, Others’ behavior and Action control should be targeted through BCTs as well as being a good mother. In the contextual factors, doers and non-doers differ in age (doers are on average 14.30 years older than non-doers) but only marginally in their households’ monthly income (123 Kenyan Shilling). Of course, we cannot change participants’ ages. However, we can tailor our interventions to the critical age group, in this case young adults. The results of this example are summarized together with the potential interpretation of the results in table 1: Interpretation of results.

 

Table 1: Interpretation of results

FactorItem / Questionmean valuedifferenceinterpretationdecision
Behavior: chlorinationHow much of your household’s drinking water do you chlorinate?Doer: 93%
Non-Doer: 54%
40%Doers chlorinate 93% of their drinking water on average, whereas non-doers only chlorinate 54% of their drinking water.selected for the intervention
health knowledgeI will present you some potential causes of diarrhea. Could you please tell me for each whether it is a cause of diarrhea or not?Doer: 2.4
Non-Doer: 2.3
0,1Doers and non-doers do not differ strongly in health knowledge.not selected for the intervention
other’s behaviorHow many people of your community chlorinate all their drinking water?Doer: 3.1
Non-Doer: 1.6
1,5Doers perceive more that others in their surrounding also chlorinate their drinking water.selected for the intervention
action controlHow keenly do you try to chlorinate all your drinking water?Doer: 2.7
Non-Doer: 1.3
1,4Doers more keenly try to chlorinate all their drinking water.selected for the intervention
reason 1: good motherWhat are your reasons to chlorinate your drinking water?Doer: 70%
Non-Doer: 30%
40%70% of the doers mention that a reason why they chlorinate their drinking water is because they want to be a good mother, only 30% of the non-doers say so.selected for the intervention
reason 2: cheapWhat are your reasons to chlorinate your drinking water?Doer: 50%
Non-Doer: 50%
0%Doers and non-doers do not differ on the frequency of mentioning the reason for chlorination that it is cheap.not selected for the intervention
respondents ageHow old are you?Doer: 42.8
Non-Doer: 28.5
14,3Doers are on average older than non-doers.considered in the intervention
monthly incomeWhat is the monthly income of your household?Doer: 3015
Non-Doer: 2892
123Doers and non-doers do not strongly differ on their monthly income.not considered in the intervention

Note that a doer/non-doer analysis was essential to determine the critical behavioral factors; a simple calculation of the mean scores in the population would have yielded other, potentially misleading, results. In this instance, examining the mean scores in the population could have led to the conclusion that Health knowledge was the most critical to target, as Health knowledge is quite low (see cell G32, bordered in violet in figure 1). However, the doer/non-doer analysis shows that doers and non-doers differ only marginally in Health knowledge (see figure 4 and table 1). In other words, Health knowledge cannot explain why some people chlorinate their drinking water (doers) while others do not (non-doers). Thus, Health knowledge is not a critical behavioral factor and should not be prioritized in an intervention.

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Phase 1:  Tools

Tool 1.7: Definitions of behavioural factors 

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Phase 1: RanasEXPLORE Specify behaviours,  behavioural factors, and context

Summary 

We first decide how the project design will look like (step 1.1 Define project design); we then define the exact behaviour to be changed and the specific population group to be targeted we specify who exactly should change which behaviour (step 1.2 Define target behaviours and target audience). Then, we collect information on the behavioural factors that might influence the target behaviour in the specific population, for example by conducting qualitative interviews (step 1.3 Explore relevant psychosocial and contextual factors). Thereby, we gain a first impression of the behavioural factors that potentially determine the target behaviour in the specific population and context. In the following, the potential behavioural factors that we have identified are included in the RANAS model (step 1.4 Complement the RANAS factors); this means adapting and extending the RANAS model to the local context. 

 

The steps of this phase are:  

1.1 Define project design 

1.2 Define target behaviours and target population

1.3 Explore behavioural and contextual factors

1.4 Specify the RANAS behavioural factors  

When planning a project, you have to define if and how reliably you want to evaluate change in behaviour and behavioural factors. Such evaluation allows to continuously improve the campaign and scale it up. The method you chose for the evaluation already requires attention when starting the project, because the project design depends on it. We recommend three options to evaluate changes and your first key action will be to choose the one which is most appropriate for your project.  

Key actions 

Define how to evaluate changes 

Option 1: Phased implementation with before-after measurement and independent comparison group 

The most reliable method to evaluate your behaviour change campaign is by comparing changes in people’s behaviour and behavioural factors in areas where you implemented the campaign (campaign group) to areas where you will implement the campaign later (comparison group). Practically, this means that, first, you measure behaviour and behavioural factors in the entire project area (baseline survey), second, implement the campaign in only one half of the project area, third, measure behaviour and behavioural factors again in the entire project area (follow-up survey), and fourth, implement the campaign in the other half of the project area. This means that at the time of the follow-up survey, only half of the project area has received the campaign. Using baseline and follow-up data, you can compute the changes in behaviour and behavioural factors for each of the two areas and compare them. This method allows for the strong conclusion that the differences between groups that you measure are due to the RANAS campaign (and not due to changes in context). We recommend to use this method whenever possible.  

Option 2: Regular implementation with before-after measurement and a natural comparison group 

However, resources, time and other considerations may not always allow to have a real comparison group as described above. In this case, your behaviour change campaign can be evaluated using a “natural comparison group”. To do so, conduct the baseline survey, implement your campaign in the entire project area and conduct the follow-up survey. In the follow-up survey, you include a “campaign check”. This means that for each participant you determine whether they have received the campaign or not. Individuals who have received the campaign or most parts of it are the campaign group. Individuals who have not received the campaign or only limited parts of it are the comparison group. You can then compute the changes in behaviour and behavioural factors for each of the two groups and compare the changes. This method provides some evidence that differences between the groups are due to your campaign. However, it is possible that specific people tend to participate more readily in your campaign than others, such as those already aware of the topic. This can bias your results.    

Option 3: Regular implementation with before-after measurement without comparison group.  

The easiest but most unreliable method is to measure behaviour change before and after the intervention in the campaign group only. To do so, you conduct the baseline survey, implement your campaign in the entire project area and conduct the follow-up survey without using the campaign check. This method may be used in stable contexts and in cases where the time between baseline and follow-up is short. However even then, regulations, seasonality, or socio-economic conditions may have changed at the same time and you cannot disentangle the effects of these context changes from the effects of your campaign. We recommend this method only if none of the others are feasible.  

Summarizing, we have the following project designs to evaluate behaviour change: 

  1. Phased implementation with before-after measurement and independent comparison group, 
  1. Implementation with before-after measurement and a natural comparison group, 
  1. Implementation with before-after measurement without comparison group.  

Ethical considerations in campaign planning 

To adhere to good ethical standards, a comparison group as mentioned in this guideline, should also receive a campaign. To be able to nevertheless receive the necessary data and findings of a comparison group, we can give the campaign to the comparison group after the implementation of the campaign and the endline evaluation (time-shifted campaign). If a time-shifted campaign is not possible, for example when working in an emergency, the comparison group could receive a standard campaign, or different campaign groups could be compared which have received different aspects of the campaign. The participating communities should be consulted to make the respective decisions conjointly or with the respective input.  

Outputs 

  • Project design 

In this step, we will define the specific behaviour to be changed and the specific population group to be targeted. In other words, we specify who exactly should change which behaviour.  

Key actions 

Define the target behaviour 

It is important to precisely define what behaviours need to be targeted by the behaviour change campaign. Taken the example of safe water consumption, one needs to define within the local context whether the campaign should target where drinking water is collected, how it is stored at home, if it needs to be treated at point of use etc. The more precisely a target behaviour is identified and described, the more effective a campaign can be designed. Box 1.1 gives more examples of behaviours relevant for health and the environment. 

Often one behaviour depends on other behaviours. To stop open defecation, first a latrine has to be constructed and kept clean. For handwashing to occur, soap and water first have to be available. For safe water to be consumed, it may be necessary to first disinfect the water and then store it safely. For proper waste management, separate bins and separated recollection needs to be organized and available.  

In order to select the appropriate target behaviour, it is useful to answer certain key questions: 

  • Which behaviours would community members like to change in their community? 
  • What are existing government programs and policies recommending? 
  • What is the current disease burden? 
  • Which environmental problems is the community exposed to or contributing to? 
  • What are ongoing activities by other actors in the community? 
  • Which behaviours are frequently practiced in the community?  
  • Which behaviours are only rarely practiced? 
  • Is the required infrastructure available? 

Conduct key informant interviews 

Even if your project team is familiar with the preferences of community members and can give responses to the key questions above, it makes sense to check your assumptions and collect additional information. For this select 5 to 10 key informants, who are individuals who you believe have an in-depth knowledge of the target community and project context. Key informants include members of the target group and decision makers. You may also select few key informants only and then ask those who else they would recommend you to interview.  Box 1.2. provides examples for questions to key informant interviews, which you can adapt. This list is not exhaustive. 

Conduct fast behaviour checks 

It makes only sense to target a behaviour for which the required infrastructure is present but which is not yet practiced consistently in the target community. Promoting latrine use, for example, does neither make sense if there are no accessible latrines nor if everybody is already using latrines for defecation. If you do not have reliable data about the prevalence of a behaviour and availability of infrastructure you need to collect them. We recommend to conduct spot check observations (see the following Box 1.3.: Examples for spot check questions) in 50 to 100 randomly selected households.  

Describe all the components of the target behaviour 

If you have successfully identified your target behaviour, you need to specify it further. A behaviour is a sequence of actions; an action is an observable single act. To define a behaviour comprehensively, we have to describe all the actions involved. Box 1.4. gives two example descriptions ‘to use a latrine’ and ‘to wash hands with soap’ 

Select the target group 

Next, we need to define the population group to be targeted. Some behaviours have different main actors while other behaviours should be practiced by everyone. Fetching water, for example, often is the task of girls or mothers while latrine construction usually falls to the domain of the male head of household. Handwashing or latrine use, on the other hand, should be practiced by everyone. But even in those cases, the behaviour of a particular group of people may have a greater influence on the household’s or population’s health, either directly (e.g. handwashing before cooking by primary caregivers) or indirectly by influencing others’ behaviour (e.g. teachers or natural leaders as role models). 

Therefore, the specific group to be targeted by an intervention typically depends on the behaviour to be changed. Different interventions may be necessary for different target groups, see Box 1.5. Examples of potential target groups. 

In order to select the appropriate target group, it is useful to answer certain key questions: 

  • Who are the persons to practice the target behaviour? 
  • Whose behaviour has the greatest influence on the family’s health or on the environment? 
  • Whose influence on other people’s behaviour is highest (who are potential role models)? 
  • Who are the persons most at risk if the behaviour is not practiced? 

 

Key resources 

  • Pre-existing information on behavioural status quo in the target population 
  • Tool for spot check observations: See Box 1.3. for examples for spot check questions 
  • Tool for Key Informant Interviews: See Box 1.2. for examples for questions to key informant interviews 

Outputs 

  • The behaviour(s) to be changed is/are defined. 
  • The target population(s) is/are defined. 
  • The project context is explored 

The step describes how to collect information on behavioural and contextual factors in order to adapt the RANAS model to the project context. Behavioural factors are elements in the mindset of a person, such as knowledge, beliefs, and emotions which can be motivators or barriers for behaviour performance. The chapter Introduction provides an overview about the RANAS behavioural and context factors. Because every population is unique, behavioural factors beyond those contained in the RANAS model may be relevant in a specific population. In addition, some behavioural factors of the RANAS model are very generic, such as “feelings” or “barriers” and need to be specified.  

Contextual factors, in contrast, are conditions outside of a person’s mindset that may facilitate or hinder a behaviour, such as existing water infrastructure or information provided at a health centre. We have started to explore these factors already during the previous step through spot-check observations and key information interviews. In this step, we will complete these insights through interviews with members of the target population. 

Key actions 

Conduct individual qualitative interviews or focus group discussions 

There are different ways of collecting data in this step. Focus group discussions are widely used, because they are time-efficient and allow discussion between participants. However, they bear the risk that the group processes and social pressure (Box 1.6.) hinder participants from expressing their opinions and beliefs freely. The following Box (1.7.) provides general instructions on conducting focus group discussions 

Individual qualitative interviews have the advantages that they focus on one participant at a time only, they allow to gather data in a more private setting and the course of the data collection can be adapted to the participant’s individual responses. Although they are more time consuming, we recommend to conduct individual qualitative interviews if possible. Box 1.8. provides general instructions on how to conduct individual qualitative interviews 

We recommend that you prepare a question guide (see Box 1.9. Examples for questions used in a qualitative interview) in advance, although the course of the interview or focus group discussion does not have to strictly follow the question guide. The guide helps to ensure that all the relevant topics are addressed. Irrespective of which tool you use, collect data from approximately 20 participants. If you chose focus groups, the size of each group should not exceed 10 participants.  

Data quality obtained from both tools is highly dependent on the skills of the data collectors. So, ideally, the project team conducts the interviews themselves instead of hiring and training interviewers. If you require additional data collectors, select (Box 2.2.2. Selection of data collectors, phase RanasMEASURE) and train (Box 2.2.3 Exemplary outline for training data collectors, phase RanasMEASURE) them carefully, including about ethical issues (see Box 1.10. Ethical issues). 

Enter the data 

It is not necessary to prepare a full transcript of an interview or a group discussion. Instead, it is sufficient to note down a short summary to each qualitative question into a table (see Box 1.11. Example of data entry table).  The table will be used in the next step 1.4, Specify the RANAS behavioural factors.  

Key resources  

  • Results from the previous step 1.2: Define target behaviour(s) and target population(s). 
  • Box 1.5: Conducting focus group discussions 
  • Box 1.6: Conducting qualitative individual interviews 
  • Tool: Question guide (see Box 1.9. for Examples for questions used in a qualitative interview)  
  • Tool Data entry table (see Box 1.11. for an Example of a data entry table) 
  • Skilled and trained data collectors (see Box 2.2.2. Selection of data collectors and Box 2.2.3 Exemplary outline for training data collectors, from phase RanasMEASURE) 

 

Outputs 

  • Potential motivators and barriers to the target behaviour in your specific target population 

In this step, we use the data collected in the previous step to adapt the RANAS model to the local project context. The resulting adapted RANAS model is thus both context specific and based on existing scientific evidence provided by the RANAS model. We will later use the adapted RANAS model to develop our quantitative questionnaire.  

Key actions 

Get familiar with the RANAS behavioural factors 

To match the factors identified in Step 1.3 to the RANAS behavioural factors, we first have to gain familiarity with the RANAS behavioural factors. Tool 1.7 provides definitions of behavioural factors along with examples of typical thoughts related to each factor.  

Specify existing factors and include additional factors 

Once we are familiar with all the RANAS behavioural factors, we summarize the results from our individual qualitative interviews and focus group discussion and allocate them to the corresponding RANAS factor (see Box 1.12. for an example of allocation of the identified behavioural and context factors to the corresponding RANAS factors). For example, the responses to the question “What are your positive feelings towards …?“ reveals which specific feelings may be relevant for the target behaviour in the specific population and should be noted under the RANAS factor feelings in the attitude factor block. The results from this type of analysis are later used to define the questions that measure the RANAS factors with the quantitative survey (see phase 2: RanasMEASURE). 

Key resources 

  • The RANAS model presented in the Introduction 
  • Results from Step 1.3: Data entry table (see Box 1.11. for an Example of a data entry table) 
  • Tool 1.7: Definitions of behavioural factors 
  • Box 1.12.:  Allocation of the identified behavioural and contextual factors to the corresponding RANAS factors  

 

Outputs  

  • The behavioural factors of the RANAS model are adapted to the local context and can be used to adapt questions in the quantitative questionnaire (see phase 2: RanasMEASURE). 

Examples of behaviours related to safe drinking water consumption: 

  • Collecting drinking water mainly (minimum 80%) from a safe source  
  • Regular cleaning of transportation containers 
  • Safe storage of drinking water at home 
  • Regular cleaning of scooping and drinking vessels 
  • Point-of-use disinfection (e.g. chlorination, boiling, filtering of drinking water) 
  • Exclusive consumption of safe water by all household members 

Examples of behaviours related to sanitation: 

  • No open defecation 
  • Constructing or purchasing toilets 
  • Using toilets 
  • Improving toilets (e.g. providing a cover or roof) 
  • Avoiding inappropriate use 
  • Cleaning toilets 
  • Emptying or paying for service 

Examples of behaviours related to handwashing with soap: 

  • Availability of water, soap and handwashing infrastructure 
  • Handwashing with soap after contact with faeces (e.g. after defecation, after cleaning child’s bottom, after removing child faeces)  
  • Handwashing with soap before handling food (e.g. before eating, before preparing food, before giving food to a child) 

Examples of other behaviours related to health and the environment: 

  • Hygienic handling and cooking of food  
  • Washing the body with water and soap 
  • Menstrual hygiene 
  • Housing hygiene (e.g. safe storage of cookware) 
  • Waste separation: availability of space for separate bins, availability of separate waste treatment 
  • Not littering: depositing waste in waste bins, emptying of bins at the official dumping site, taking garbage home when no bins are available 
  • How safe is this area?   
  • Are there schools in the area?  
  • What are the most pressing problems in this area?  
  • Are there certain behaviours, that you would like to see changed in the community?  
  • Who of the household members is responsible for decision making regarding the target behaviour?  
  • What kind of projects are going on in the area about the target behaviours?   
  • Is hardware for the behaviour available in the area? (Toilets, sinks, handwashing stations etc.)  
  • How often do people perform the target behaviour?  
  • How many people regularly perform the target behaviour?  
  • Which activities have been implemented?   
  • Who realized those activities?   
  • Interviewers observe the following, depending on the target behaviour: 
  • Water treatment – solar water disinfection (SODIS)  
  • Are there any PET bottles placed outside the house?  
  • How many?  
  • Where?  
  • Are they in the sun?  
  • Is the water in the bottles clear? 
  • Water container 
  • Does the storage container have a cover?   
  • If yes: Is it presently fully covered?   
  • Open defecation and latrine use  
  • Are there any human excreta in the wider surrounding of the house?  
  • Is there access to a latrine for defecation?  
  • Does the latrine smell (fecal odors)?  
  • Are flies present?  
  • Handwashing: 
  • Where is the hand washing place located? 
  • Which water device is present for handwashing? 
  • Is water present? 

The behaviour of using a latrine implies the following actions: 

  • Walk to the latrine, open the door, and remove the cover (preparatory actions). 
  • Defecate, clean the anus (main actions). 
  • Cover the latrine, (wash hands), leave the latrine, close the door, walk back (finalizing actions). 

The behaviour of handwashing implies the following actions: 

  • Walk to handwashing facility (preparatory actions) 
  • Wet hands, apply soap, lather and scrub for 20 sec, rinse hands with water for 10 sec, dry hands in the air or with a clean towel (main actions) 
  • Walk back (finalizing actions). 
  • Women/Men 
  • Primary caregivers 
  • Heads of households 
  • Children 
  • Pupils 
  • Leaders 
  • Teachers 
  • Mothers/Fathers 
  • Most vulnerable (e.g. disabled persons) 

Keep in mind that group processes and social pressure can substantially impair focus group discussion outcomes. Distorting influences may be: 

  • Past events and existing alliances among participants are likely to replicate in the group discussion and will influence all participants’ behaviours, interactions, and answers.  
  • The first topic emerging in a discussion bears the risk that participants stick to it and neglect other relevant topics.  
  • Silent participants who do not share their thoughts. 
  • Minorities’ opinions may be overheard (especially in larger groups).  
  • Status differences that exist between participants in real life may prevail so that some participants are not allowed to speak or do not feel comfortable sharing their thoughts. 
  • Dominant participants may be the only ones defining the topics and using most of the discussion time. 
  • Leaders and respected people may dominate the discussion. 
  • Hidden agendas may make participants presenting biased information that serves their personal interests. 

Tips to minimize group processes and social pressure in focus group discussions: 

  • Depending on the culture, organize separate meetings for women and men. 
  • Depending on the culture, organize separate meetings for different social groups (e.g. people of different status).  
  • Try to include all participants in the discussion by explicitly asking specific participants (e.g. silent participants) to share their opinions and thoughts. 
  • Ask participants to brainstorm first and if possible, write down or draw their answers. Every participant is then invited to share these points. 

Preparations: 

  • Select the participants. They should be part of the target group you have specified in 1.2 (e.g. primary caregivers) 
  • Consider Box 1.4 when selecting participants and decide carefully, who you invite together.  
  • In any case schedule separate discussions with doers and non-doers. 
  • Use Tool 1c to prepare the questionnaire guide.  
  • Prepare questions on both the target behaviour and the competing, undesired behaviour. 
  • Material: paper cards, pens, flipchart, tape 
  • Staff: One moderator and one note taker.  

Introduction and consent:  

  • Give introductory information about the target behaviour and that you are interested in the participants’ opinions regarding advantages, disadvantages, and barriers to the behaviour. 
  • Explain that participants help you and the community most by giving answers that truly represent their opinions.  
  • Explain that you are interested in participants’ thoughts and opinions and not in any particular answers and that there are no right or wrong answers. 
  • Obtain participants’ agreement to conducting and documenting the discussion. 
  • Make a list of all participants, their age, gender and (if relevant) position (or why they have been included into the FGD. 

Procedure 

  • The moderator poses the first question from the interview guide, and lets participants write their answers in short expressions (one or a few words) on cards (1 to max. 5 per person).  
  • Once every participant is content with the words they wrote, each participant explains each card and hands it to the moderator, who one by one (as they keep arriving) groups the cards by content, e.g. by sticking them to the wall or blackboard.  
  • When all cards are grouped, participants discuss the result and if necessary, cards are moved.  
  • Each category is then given a headline and a photo is taken. The co-moderator writes down an explanation / resumption of results. 
  • Repeat this process for each behavior; if necessary, with a new group of participants. 

Preparations: 

  • Select the participants. They should be part of the target population you have specified in 1.2 (e.g. primary caregivers) 
  • Use Tool 1c to prepare the questionnaire guide.  
  • Prepare questions on both the target behaviour and the competing, undesired behaviour.  
  • Material: Notebook or printed question guide with spaces for responses, pen 
  • Staff: One data collector 

Introduction and consent:  

  • Engage the participant in some easy conversation. 
  • Give introductory information about the target behaviour and that you are interested in participants’ opinions regarding advantages, disadvantages, and barriers to the behaviour. 
  • Explain that participants help you and the community most by giving answers that truly represent their opinions.  
  • Explain that you are interested in participants’ thoughts and opinions and not in any particular answers and that there are no right or wrong answers. 
  • Obtain participants’ agreement for conducting and documenting the interview. 
  • Note the participant’s age and gender  

Procedure: 

  • Conduct the interview following the question guide. 
  • Try to collect answers to all predefined questions. 
  • Ask free additional follow-up questions whenever a topic of particular interest is raised. 
  • Try to lead the participants back to your main topic whenever the interview or discussion has strayed away from your main topic. 
  • At the end, sum up the main points of the interview or discussion. 
  • Close the interview or discussion by thanking the participants for their help and asking whether they have any final comments or questions. 
  • Immediately after: finalize the notes. 
Behavioural Factor Questions  
Behaviour How do you or others perform… (frequency, timings, place, materials)? 
Feelings What do you dislike about…? 
Benefits What do you think are the advantages of …?  
Barrier planning 

Do you see any barriers/problems to perform …?   

Tell me about any situations when you do not (or are unable to) perform …?  

Others’ (dis)approval To whom would you like to listen to what he/she has to say about …? 

Personal privacy: 

  • Personal privacy must be respected 
  • Enter homes only when invited to enter 
  • Conduct interviews in a place without disturbance 
     
    Informed consent: 
  • Inform participants about the study purpose and procedures in a language understandable to them 
  • The participant explicitely agrees with the participation 
     
    Voluntary participation: 
  • There is no obligation to participate 
  • The interviewee is free to not answer some questions 
  • The interviewee is free to quit the interview anytime 
     
    Confidentiality: 
  • The answers are treated confidentially / stay within the group 
     
    No promises: 
  • No gifts for participation 

Enter each question in a separate row in columns 1 of your table. In the subsequent columns, enter the responses of your respondents. Use a separate column for each respondent.   

Questions  

Behavioural factor 

Respondent /focus group 1 

Respondent / focus group 2 

 

How do you or others perform… (frequency, timings, place, materials)? 

Behaviour 

 

 

 

 What do you dislike about…? 

Feelings 

 

 

 

What do you think are the advantages of …?  

Benefits 

 

 

 

Do you see any barriers/problems to perform …?   

Tell me about any situations when you do not (or are unable to) perform …?  

Barrier planning 

 

 

 

To whom would you like to listen to what he/she has to say about …? 

Others disapproval 

 

 

 

 

Take the results from the qualitative interview data entry table and check for each question, whether you can identify any reoccurring pattern. For example, are there feelings which are named by several respondents? Which barriers are most frequently mentioned? Of you have conducted focus group discussions, you would already have this summary. Next, consider the following table and write the results next to the RANAS factor they correspond to. If there are results which do not match any of the RANAS factors, write them under “additional factors” at the bottom of the table. The following table contains some example results.  

RANAS behavioural factors 

Corresponding result from qualitative interviews or focus group discussions (Examples for HW) 

Beliefs about Costs and Benefits 

Handwashing with soap is time-consuming.  

Feelings 

Feeling clean after handwashing. 

Not liking scent of soap. 

Others’ Behavior 

It is a family custom to wash hands. 

Others’ (Dis)Approval 

Having been told to do so during childhood. 

Barrier Planning 

Lack of time to integrate handwashing into daily routines. 

 

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Box 2.2.1: Two approaches to questionnaire translation

Employ translators

When hiring a translator, it is important that the translator (1) is informed about the RANAS model and the specific meaning of the behavioral factors so as to translate the questions appropriately and (2) is not only familiar with the local language but with the specific vocabulary and dialect of the target population. Ideally, to verify the quality of the translation, it is back-translated into the original language by a second translator and compared with the original questionnaire. Where differences arise between the original and the back-translated versions, the translations have to be revised.

Translate together with the data collectors during training

An alternative approach is to translate the questionnaire, or at least the key words of each question and response option, into the local language while training the data collectors. This approach may be preferable, because the data collectors (1) gain a more detailed understanding of the questionnaire and the underlying model, which will help them during the interviews, (2) perceive the translated questionnaire as a collective output, and (3) are therefore more strongly committed to asking the questions as jointly agreed. An essential is the presence of the local supervisor, who has learned about the RANAS approach in detail and can assist in the joint translation of the questionnaire.

Box 3.2.: Data entry and division of the sample into doers and non-doers

Phase 4:  Outputs

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Box 4.5. Integrating existing activities and materials

Many times, partner organizations already have experience in implementing behaviour change activities and materials may already exist. In this case we have to carefully review the existing activities and materials together with the staff of the organization and allocate them to the BCTs in the RANAS catalogue of BCTs. We should even analyse in detail the messages and activities and specify the behavioural factors they address. This process contributes to a better understanding of the new RANAS BCTs. It prevents to fall back into old habits of risk promotion because, the differences between old and new activities become clear. And finally, this process may save costs, because it allows existing material to be re-used.

Phase 2:  Outputs

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Phase 5:  Outputs

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Phase 1:  Outputs

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Phase 6:  Outputs

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Phase 5:  Tools

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Phase 5:  Tools

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Phase 3:  Tools

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Phase 2:  Tools

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Tool 1.7: Definitions of behavioural factors 

Definitions of behavioural factors 
RANAS behavioural factors  Definitions  Examples of typical thoughts 
Risk factors, representing a person’s understanding and awareness of the health risk 
Health Knowledge  A person’s knowledge about a disease’s causes, personal consequences, and preventive measures.  “If I drink raw water I might get diarrhea”. 
Vulnerability  A person’s estimation of the general probability of contracting a disease and subjective awareness of the personal risk of contraction.  “The risk that I get diarrhea is high”. 
Severity  A person’s assessment of the seriousness of an infection and the significance of the disease’s consequences.  “If I get diarrhea I cannot go to the market to sell my products, so I lose money”. 
Attitude factors, representing a person’s positive or negative stance towards a behavior 
Beliefs about Costs and Benefits  A person’s beliefs about the monetary and non-monetary costs (time, effort etc.) and benefits (lower medical costs, improved health) of a behavior, including social benefits (higher status, appreciation by others).  “Fetching water at the safe source is time-consuming”. 
Feelings  A person’s emotions (joy, pride, disgust etc.) when thinking of a behavior or its consequences or when practicing the behavior.  “I like to wash hands with soap”. 
Norm factors, representing the perceived social pressure towards a behavior 
Others’ Behavior  A person’s observation and awareness of others’ behavior, his or her perceptions of which behaviors are typically practiced by others.  “Nearly all community members use a latrine for defecation”. 
Others’ (Dis)Approval  A person’s perceptions of which behaviors are typically approved or disapproved of by relatives, friends, and neighbors. This includes awareness of institutional norms, i.e. the dos and don’ts expressed by recognized authorities such as village, tribe, and religious leaders or other institutions.  “My relatives approve when I chlorinate my drinking water”. 
Personal Importance  A person’s beliefs about what she or he should do or should not do.  “I feel personally obliged to wash hands with soap before I feed my baby”. 
Definitions of behavioural factors (continued) 
RANAS behavioural factors  Definitions  Examples of typical thoughts 
Ability factors, representing a person’s confidence in her or his ability to practice a behavior 
How-to-do Knowledge  A person’s knowledge of how to execute the behavior.  “When I chlorinate my drinking water, I have to leave the water to stand for at least 30 minutes before drinking it”. 
Confidence in Performance  A person’s perceived ability to organize and execute the courses of action required to practice a behavior.  “I am confident in my ability to use the water filter correctly”. 
Confidence in Continuation  A person’s perceived ability to continue to practice a behavior, which includes the person’s confidence in being able to deal with barriers that arise.  “I am confident that I can find the time and money to regularly buy all drinking water at the safe source”. 
Confidence in Recovering  A person’s perceived ability to recover from setbacks, to continue the behavior after disruptions.  “I am confident in my ability to restart using the latrine for defecation even after it was broken for several weeks”. 
Self-regulation factors, representing a person’s attempts to plan and self-monitor a behavior and to manage conflicting goals and distracting cues 
Action Planning  The extent of a person’s attempts to plan a behavior’s execution, including the when, where, and how of the behavior.  “I plan to refill the water filter every evening before going to sleep”. 
Action Control  The extent of a person’s attempts to self-monitor a behavior by continuously evaluating and correcting the ongoing behavior toward a behavioral goal.  “Yesterday I arrived late at the borehole and it was already closed; so today I really have to remember to go in time!” 
Barrier Planning  The extent of a person’s attempts to plan to overcome barriers which would impede the behavior.  “If I don’t have enough soap at home I won’t be able to wash my hands regularly. Therefore I keep a stock of two soaps in the cupboard and refill it as necessary every market day”.  
Remembering  A person’s perceived ease of remembering to practice the new behavior in key situations.  “Every evening before going to sleep I drink a cup of water and thus remember to refill the water filter”. 
Commitment  The compulsion a person feels to practice a behavior.  “I am committed to drinking only chlorinated water”. 

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Tool 4.5. Example campaign instruction & template for piloting

Household Visits 1

What you need
aInfection diagram in one piece
bInfection diagram as puzzle
cInfection prevention pictograms
dTemplate to note feelings

 

Activity 1: Introduction and Recap

Ranas factor blockRanas factorRanas BCT

 

Objective
Primary caregivers (participants) are ready to participate in this household visit, trust the promoter and feel comfortable in his/her presence.

 

How to do the activity Notes: Acceptability Notes: Feasibility
Step 1Approach the household and engage in an informal conversation to find out if there are children below 5 years in the household.   
Step 2Find out who is the primary caregivers (participant) and request 15 minutes of his/her time.   
Step 3Engage the participant in an informal conversation and lead the topic towards hand hygiene.   
Step 4Ask the participant if he/she would like to learn more about hand hygiene.   

 

Activity 2: Interactive Infection and Prevention Diagram

RANAS factor blockRANAS factorRANAS BCT
RisksHealth knowledgeBCT 1: Present facts
Objective
Participants understand how diarrhoea is transmitted how these transmissions can be prevented through handwashing with soap, covering food, latrine use and consuming safe drinking water.
How to do the activityNotes: Acceptability Notes: Feasibility
Step 1Ask the participants to think of the main ways in which diarrhoea is transmitted and listen to their answers.   
Step 2Show the infection diagram (a) to participants and explain the route of transmission. Remove the infection diagram from view.   
Step 3Hand over the infection diagram puzzle (b) to the participants. Ask them to compile the diagram from memory.   
Step 4Let participants explain the infection diagram in their own words.   
Step 5Ask participants what they can do to prevent diarrhoea. Hand over the respective infection prevention pictograms (c) to participants as they are mentioning them. Let them put the infection prevention pictograms (c) on the right places completed infection diagram puzzle (b). Help if needed.   
Step 6Hand over the remaining pictograms to participants one-by-one. Ask them how the respective behaviour prevents diarrhoea. Proceed as during step 5.   
Step 7The infection diagram has become a prevention diagram. Let participants explain the prevention diagram in their own words.   
Step 8If they are comfortable, request participants to gather all household members and let them explain the prevention diagram to them.   
Tips

·       Give participants time to talk and explain their views

·       Correct mistakes

·       Practice this activity with a friend or colleague until you feel comfortable applying it

Activity 3:

Ranas factor blockRanas factorRanas BCT
AttitudesFeelingsBCT 9: Describe feelings about performing and about consequences of the behaviour
Objective
Participants are aware of their feelings when washing hands.
How to do the activityNotes: Acceptability Notes: Feasibility
Step 1Request participants to take a moment, breathe slowly and focus on what they are feeling in this moment. They may close their eyes.   
Step 2Let participants imagine that they are washing hands, step-by-step in the way they usually do.   
Step 3Which feelings do they have?   
Step 4Request participant to open their eyes and share the feelings they had.   
Step 5Note the feelings on the template (d)   
Step 6Request participants to actually wash hands. What are their feelings now?   
Step 7Add feelings to the template (d)   
Step 8And finally request participants to imagine they had not washed hands. What would be the feelings   
Step 9Add the feelings to the template (d) and hand it over to the participant.   
Step 10Ask participants to select 2 feelings, that they felt strongest and request them to remember them when washing hands. When you are washing hands, you can take this as a break from your daily life by focusing on yourself.    
Tips

·       Give participants time to talk and explain their views

·       Practice this activity with a friend or colleague until you feel comfortable applying it

Reference and further information

Activity 2 has been adapted from the Watsan Mission Assistant developed by the International Federation of Red Cross and Red Crescent Societies.2 : https://watsanmissionassistant.org/wp-content/uploads/2018/10/147500-contamination-explanation-en.pdf The material for these activities has been developed for Ministry of Health, Republic of Indonesia and UNICEF (2021). Behaviour change interventions for strengthening

Handwashing with Soap (HWWS) in Indonesia: A training guide for facilitators and practitioners. UNICEF Indonesia.

Jakarta, 2021.

Activity 2, Material a and b: Infection diagram in one piece and as puzzle

Activity 2, Material c: Infection prevention pictograms (left) and instructions where to place them (right)

Activity 3, Material d: Template to note feelings

© Copyright Ranas Ltd. Use only under Creative Commons License CC BY-NC-ND 4.0; 

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Tool 4.4. Example campaign instruction

Household Visits 1

What you need
aInfection diagram in one piece
bInfection diagram as puzzle
cInfection prevention pictograms
dTemplate to note feelings

 

Activity 1: Introduction and Recap

Ranas factor blockRanas factorRanas BCT

 

Objective
Primary caregivers (participants) are ready to participate in this household visit, trust the promoter and feel comfortable in his/her presence.

 

How to do the activity
Step 1Approach the household and engage in an informal conversation to find out if there are children below 5 years in the household. 
Step 2Find out who is the primary caregivers (participant) and request 15 minutes of his/her time. 
Step 3Engage the participant in an informal conversation and lead the topic towards hand hygiene. 
Step 4Ask the participant if he/she would like to learn more about hand hygiene. 

Activity 2: Interactive Infection and Prevention Diagram

RANAS factor blockRANAS factorRANAS BCT
RisksHealth knowledgeBCT 1: Present facts
Objective
Participants understand how diarrhoea is transmitted how these transmissions can be prevented through handwashing with soap, covering food, latrine use and consuming safe drinking water.
How to do the activity
Step 1Ask the participants to think of the main ways in which diarrhoea is transmitted and listen to their answers. 
Step 2Show the infection diagram (a) to participants and explain the route of transmission. Remove the infection diagram from view. 
Step 3Hand over the infection diagram puzzle (b) to the participants. Ask them to compile the diagram from memory. 
Step 4Let participants explain the infection diagram in their own words. 
Step 5Ask participants what they can do to prevent diarrhoea. Hand over the respective infection prevention pictograms (c) to participants as they are mentioning them. Let them put the infection prevention pictograms (c) on the right places completed infection diagram puzzle (b). Help if needed. 
Step 6Hand over the remaining pictograms to participants one-by-one. Ask them how the respective behaviour prevents diarrhoea. Proceed as during step 5. 
Step 7The infection diagram has become a prevention diagram. Let participants explain the prevention diagram in their own words. 
Step 8If they are comfortable, request participants to gather all household members and let them explain the prevention diagram to them. 
Tips

·       Give participants time to talk and explain their views

·       Correct mistakes

·       Practice this activity with a friend or colleague until you feel comfortable applying it

Activity 3:

Ranas factor blockRanas factorRanas BCT
AttitudesFeelingsBCT 9: Describe feelings about performing and about consequences of the behaviour
Objective
Participants are aware of their feelings when washing hands.
How to do the activity
Step 1Request participants to take a moment, breathe slowly and focus on what they are feeling in this moment. They may close their eyes. 
Step 2Let participants imagine that they are washing hands, step-by-step in the way they usually do. 
Step 3Which feelings do they have? 
Step 4Request participant to open their eyes and share the feelings they had. 
Step 5Note the feelings on the template (d) 
Step 6Request participants to actually wash hands. What are their feelings now? 
Step 7Add feelings to the template (d) 
Step 8And finally request participants to imagine they had not washed hands. What would be the feelings 
Step 9Add the feelings to the template (d) and hand it over to the participant. 
Step 10Ask participants to select 2 feelings, that they felt strongest and request them to remember them when washing hands. When you are washing hands, you can take this as a break from your daily life by focusing on yourself.  
Tips

·       Give participants time to talk and explain their views

·       Practice this activity with a friend or colleague until you feel comfortable applying it

Reference and further information

Activity 2 has been adapted from the Watsan Mission Assistant developed by the International Federation of Red Cross and Red Crescent Societies.2 : https://watsanmissionassistant.org/wp-content/uploads/2018/10/147500-contamination-explanation-en.pdf. The material for these activities has been developed for Ministry of Health, Republic of Indonesia and UNICEF (2021). Behaviour change interventions for strengtheningHandwashing with Soap (HWWS) in Indonesia: A training guide for facilitators and practitioners. UNICEF Indonesia.

Jakarta, 2021.

Activity 2, Material a and b: Infection diagram in one piece and as puzzle

Activity 2, Material c: Infection prevention pictograms (left) and instructions where to place them (right)

Activity 3, Material d: Template to note feelings

© Copyright Ranas Ltd. Use only under Creative Commons License CC BY-NC-ND 4.0; 

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Phase 4 Tool. Example campaign instruction

Household Visits 1

What you need
aInfection diagram in one piece
bInfection diagram as puzzle
cInfection prevention pictograms
dTemplate to note feelings
 Appointment with participants
  
  
  

Activity 1: Introduction and Recap

Ranas factor blockRanas factorRanas BCT

 

Objective
Primary caregivers (participants) are ready to participate in this household visit, trust the promoter and feel comfortable in his/her presence.

 

How to do the activity
Step 1Approach the household and engage in an informal conversation to find out if there are children below 5 years in the household. 
Step 2Find out who is the primary caregivers (participant) and request 15 minutes of his/her time. 
Step 3Engage the participant in an informal conversation and lead the topic towards hand hygiene. 
Step 4Ask the participant if he/she would like to learn more about hand hygiene. 

 

Activity 2: Interactive Infection and Prevention Diagram

Ranas factor block Ranas factor Ranas BCT
Risks Health knowledge BCT 1: Present facts
Objective
Participants understand how diarrhoea is transmitted how these transmissions can be prevented through handwashing with soap, covering food, latrine use and consuming safe drinking water.
How to do the activity
Step 1 Ask the participants to think of the main ways in which diarrhoea is transmitted and listen to their answers.
Step 2 Show the infection diagram (a) to participants and explain the route of transmission. Remove the infection diagram from view.
Step 3 Hand over the infection diagram puzzle (b) to the participants. Ask them to compile the diagram from memory.
Step 4 Let participants explain the infection diagram in their own words.
Step 5 Ask participants what they can do to prevent diarrhoea. Hand over the respective infection prevention pictograms (c) to participants as they are mentioning them. Let them put the infection prevention pictograms (c) on the right places completed infection diagram puzzle (b). Help if needed.
Step 6 Hand over the remaining pictograms to participants one-by-one. Ask them how the respective behaviour prevents diarrhoea. Proceed as during step 5.
Step 7 The infection diagram has become a prevention diagram. Let participants explain the prevention diagram in their own words.
Step 8 If they are comfortable, request participants to gather all household members and let them explain the prevention diagram to them.
Tips
·       Give participants time to talk and explain their views ·       Correct mistakes ·       Practice this activity with a friend or colleague until you feel comfortable applying it

Activity 3:

 

Ranas factor blockRanas factorRanas BCT
AttitudesFeelingsBCT 9: Describe feelings about performing and about consequences of the behaviour
Objective
Participants are aware of their feelings when washing hands.
How to do the activity
Step 1Request participants to take a moment, breathe slowly and focus on what they are feeling in this moment. They may close their eyes. 
Step 2Let participants imagine that they are washing hands, step-by-step in the way they usually do. 
Step 3Which feelings do they have? 
Step 4Request participant to open their eyes and share the feelings they had. 
Step 5Note the feelings on the template (Material X) 
Step 6Request participants to actually wash hands. What are their feelings now? 
Step 7Add feelings to the template (Material X) 
Step 8And finally request participants to imagine they had not washed hands. What would be the feelings 
Step 9Add the feelings to the template (Material X) and hand it over to the participant. 
Step 10Ask participants to select 2 feelings, that they felt strongest and request them to remember them when washing hands. When you are washing hands, you can take this as a break from your daily life by focusing on yourself.  
Tips

·       Give participants time to talk and explain their views

·       Practice this activity with a friend or colleague until you feel comfortable applying it

Reference and further information
Activity 2  has been adapted from the Watsan Mission Assistant developed by the International Federation of Red Cross and Red Crescent Societies.2 : https://watsanmissionassistant.org/wp-content/uploads/2018/10/147500-contamination-explanation-en.pdf

Activity 2, Material a and b: Infection diagram in one piece and as puzzle

© Copyright Ranas Ltd. Use only under Creative Commons License CC BY-NC-ND 4.0; 

https://creativecommons.org/licenses/by-nc-nd/4.0/  

Phase 4:  Tools

Phase 4 Tool. Example campaign instruction

Tool 4.4. Example campaign instruction

Tool 4.5. Example campaign instruction & template for piloting

© Copyright Ranas Ltd. Use only under Creative Commons License CC BY-NC-ND 4.0; 

https://creativecommons.org/licenses/by-nc-nd/4.0/  

Box 4.6. Example campaign materials

………

Box 2.2: Box: Formulating meaningful response options

Requirements Examples Explanations
The grades should be of a consistent breadth. Example with a consistent breadth: 1 ¨ Never 2 ¨ Seldom 3 Sometimes 4 ¨ Often 5 ¨ Always Example with inconsistent breadth: 1 ¨ Never 2 ¨ Sometimes 3 ¨ Often 4 ¨ Very often 5 ¨ Always Only with a consistent breadth can we calculate mean values in Step 2.3. In the lower example, the breadth between grade 0 and 1 is larger, and between 2, 3 and 4 smaller than between 1 and 2.
The scale at best contains 5 grades. Example with 3 grades: 1 ¨ Never 2¨ Often 3 ¨ Always Example with 5 grades: 1 ¨ Never 2 ¨ Seldom 3 ¨ Sometimes 4 ¨ Often 5 ¨ Always With less than 5 grades, the rating scale is not able to differentiate adequately between participants. With more than 5 grades, participants tend to be overwhelmed by the number of response options and the degree of differentiation.

Box 2.2.2: Selection of data collectors

Requirements:
  • Local –
    • Shares the same mother tongue, and preferably the same dialect, as the target population
    • Is familiar with the local customs and social protocols so as to increase acceptance within the target population
  • Fluent in a language shared with the project leader
  • Socially competent
  • Good communication skills
  • Respectful and attentive behaviour in dealing with participants
Advantages of appointing health promoters as data collectors:
  • No recruitment necessary
  • They know the projects
  • We know them already
Disadvantages of appointing health promoters as data collectors:
  • It may be difficult for them to change from the role of health promoter to that of an objective data collector who exerts no influence. This is especially true during the survey after the intervention.
  • Participants may be inclined to distort their responses to please former promoters with exemplary answers. Again, this is especially true during the follow-up survey.

Box 2.2: Box: Formulating meaningful response options

RequirementsExamplesExplanations
Precise

“At what time of the day do you usually go to fetch water?”

  1. ¨ Morning
  2. ¨ Afternoon
  3. ¨ Evening The answer options of the first question are very broad. Therefore, we cannot gain much information.
  4. ¨ Irregularly

“At what time of the day do you usually go to fetch water?”

  1. ¨ Morning, before preparing breakfast
  2. ¨ Morning, before eating breakfast
  3. ¨ Morning, after breakfast
  4. ¨ Morning, before preparing lunch
  5. ¨ Noon, before eating lunch
  6. ¨ Afternoon, after lunch
  7. ¨ Afternoon, before preparing dinner
  8. ¨ Evening, before eating dinner
  9. ¨ Evening, after dinner
  10. ¨ Evening, before going to sleep 11 ¨ Irregularly

The answer options of the first question are very broad. Therefore, we cannot gain much information.

For the second question, the answer options are much more specific, and we gain a clear picture about when a person fetches water. Note. Depending on the context, people may not be used to thinking in hours. Therefore, specifying the time (e.g. at 9am) may be difficult for them. Often it is more appropriate to ask about tasks which they do before or after.

Box 1.5: Visual Scale

The visual scale can help participants to complete the questionnaire. The visual scale is used for answer scales with 5 grades where the answers are increasing (i.e. from “not at all” to “very much”).

  • Every circle represents one answer option
  • For the first four to five questions, the interviewer reads the answer options of the question while pointing to the respective circles.
  • Later on, the respondent formulates the answer while showing it on the circles.
  • For each question, the participant needs to say his/her answer and point on the according circle. If the concept is not understood, the interviewer needs to repeat the answer options again
How to use a visual scale (example dialogue)

Interviewer: How much do you like the taste of chlorinated drinking water? Do you like it not at all (interviewer points at the smallest circle), do you like it a little bit (interviewer points at the second circle), do you quite like it (interviewer points at the third circle), do you like it (interviewer points on the fourth circle), do you like it very much (interviewer points on the fifth circle). Please choose one of the answer options by pointing on the according circle and say your chosen option.

Participant: I like it a little (participant points at the second circle).

Interviewer takes notes on the answer and continues with the next question by reading out the answer options again. S/he repeats this for four to five questions until the respondent has understood the concept and can point on the corresponding circle immediately and say his/her chosen answer option.

Option:

The scale can be introduced by using an example: Imagine the rising sun. In the morning, the sun is not at all hot (point at the first circle), then during the morning it gets hotter (point on the second circle) and hotter (point at the third circle), one hour before noon it is already hot (point at the fourth circle) and at noon it is very hot (point at the fifth circle). Other examples can be comparing the rising feeling of being hungry or sleepy.

Box 2.2: Advantages and disadvantages of data collection methods

Requirements Explanations Examples
Simple Formulate the question as simple and straightforward as possible. yes: “How much do you think that washing hands with soap before eating is time-consuming or not time-consuming?” no: “How much do you think that if you wash your hands with soap before you eat that this consumes much time or consumes not much time?”
Short While the meaning of the first two questions is essentially the same, the first includes additional aspects or information which is not necessary but lengthens the question. If you have to ask a long, complex question (see third and fourth questions), to increase comprehension try to break it into several sentences (as in the fourth question). no: “How much do you think that it may be disgusting or not disgusting if you drink untreated water which you had fetched from an unsafe water source?” yes: “How disgusting is drinking untreated water to you?” no: “How confident or unconfident are you to start washing hands with soap before handling food again after you had stopped to wash hands for several days, for example because there was no water or soap for handwashing?” yes: “Imagine you have stopped washing hands with soap before handling food for several days, for example because there was no water or soap for handwashing. How confident are you to start washing hands with soap and water before handling food again?”
Concrete With the first question, we only gain information on whether the participant washes hands or not. However, no information is gained with regard to the handwashing agent or with regard to the key time. With the second question, we gain information on whether hands are washed with a specific agent at a specific key time. no: “Do you wash your hands?” yes: “Do you wash your hands with soap and water before eating?”
Unidimensional, without “and” or “or” The question contains two separate ratings, one regarding the temperature and one regarding the color of the water. A response may represent a weighting of the two aspects or the rating of that one aspect which is more important to the participant. no: “How much do you like the temperature and the color of the water?”
Without expressions unfamiliar to the target  population Depending on the sample, participants may or may not be familiar with the term abdominal typhus. In the latter case, the disease would first have to be explained to the participant. no: “Have you ever suffered from abdominal typhus?”
Not suggestive The first question implies that drinking untreated water is disgusting. The second question (1) emphasizes the subjectivity of the rating, and (2) leaves open whether it is disgusting or not. no: “Do you agree that drinking untreated water is disgusting?” Yes: “How much do you think that drinking untreated water is disgusting?”
Careful regarding sensitive topics Often the question is not so much whether it is possible to talk about a sensitive topic at all but rather which words are appropriate to use. Which topics are sensitive and which words are appropriate depend on the specific local context. In one context, for example, it is more appropriate to ask about “defecation”, while in another the appropriate word may be “pooping”. “Where do you go to defecate?” “Where do you go to poop?”
In line with the response options While the question is formulated as a yes-no question, the response option is a rating scale. no: “Do you like the temperature of the water?” 1 ¨ Not at all 2 ¨ A little 3 ¨ Quite 4 ¨ Much 5 ¨ Very much

Box 6.2. Examples for campaign check items

  • Have you participated in any activities about behaviour A during the last six months? 
  • Did you receive any materials to do with behaviour A during the last six months? 
  • Were you visited by a health or NGO worker to talk about behaviour A during the last six months? 
  • Was the information you received useful / interesting / relevant? 
  • Did you receive information about behaviour A any other way? 

Box 6.1. Evaluation option if a BAC is not posible

In case you did not or could not plan for a before-and-after comparison and a campaign and comparison group, here is what can be done: 

  • Without baseline, the current trend in the campaign group can be compared to a comparison group where the campaign was not yet implemented.  
  • Without a comparison group, before-and-after data can be compared and the campaign check used to create an artificial comparison group (people amongst the campaign group who did not receive all messages or activities or who liked them less). 
  • Without baseline and without a comparison group, you can ask participants about their current perception of the campaign and / or about their current behaviour. 

Box 5.1. Model checklist

Print the respective checklist and give it as supportive material to the promoter(s) during the promoter training.  

The checklist should correspond to the BCTs that were selected and one checklist for each communication channel should be prepared.  

 Communication channel: Household visits 
Step Activity & message  ✓ ? 
1 Promoter introduces him-/herself and asks for permission to talk about the topic at hand (the desired behavior).   
2 The promoter asks questions related to the topic / behavior at hand, to break the ice and find out the relevant practices in the household he/she is visiting.   
3 

Promoter demonstrates the correct behavior (depending on BCTs) and its steps and/or explains / gives the chosen key messages:  

1. 

2. 

3. 

 

 
4 

Promoter realizes the chosen activities according to BCTs:  

1. 

2. 

3. 

 

 
5 The promoter gives space for questions and/or discussion of possible barriers and problems (depending on BCTs).   
6 The promoter hands out and explains how to use the agreed materials (depending on BCTs and communication channels).   
7 The promoter thanks the participants. If part of the project, permission is asked to visit again, and appointments made.   

Box 2.2: Advantages and disadvantages of data collection methods

Open questions
DescriptionExamplesFurther information
  • The interviewer reads the question.
  • The participant answers in his/her own words.
  • The interviewer writes down the answer(s).

For multiple-response questions:

If the participant keeps silent after a response, the interviewer asks ‘Anything else?’ Only when the participant responds ‘No’, the interviewer proceeds to the next question.

Single-response question: What is the single most important reason to collect your drinking and cooking water at the arsenic safe well?

Multiple-response question: What are the advantages of collecting your drinking and cooking water at the arsenic safe well?

Advantages:

  • We get the participant’s own answers.
  • Allows exploration of the range of possible topics arising from an issue, including those that we had not anticipated.

Disadvantages:

  • Time-consuming for the participant and the interviewer.
  • Answers are difficult to code and compare.
  • Time-consuming for the data processing, as the responses have to be categorized.
  • Open multiple-response questions: Difficult to analyse.
Open questions with given response options
DescriptionExamplesFurther information
  • The interviewer reads the question.
  • The participant answers in his/her own words.
  • Based on the answer(s), the interviewer selects the corresponding response option(s).

For multiple-response questions:

If the participant keeps silent after a response, the interviewer asks ‘Anything else?’ Only when the participant responds ‘No’, the interviewer proceeds to the next question.

Single-response question: What is the single most important reason to collect your drinking and cooking water at the arsenic safe well?

1 ¨ Taste

2 ¨ Distance

88 ¨ Other……………….

Multiple-response question: What are the advantages of collecting your drinking and cooking water at the arsenic safe well?

1 ¨ Taste

2 ¨ Distance

88 ¨ Other……………….

Advantage compared to the previous format: Responses are pre-categorized to facilitate data gathering, entry, and processing.
Prerequisite: knowledge about the most common responses.Disadvantage of open multiple-response questions: Difficult to analyse.
Open questions
DescriptionExamplesFurther information
  • The interviewer reads the question and the response options.
  • The participant chooses a response option.
  • The interviewer ticks the chosen response option.

Unipolar: How much do you think that collecting all your drinking and cooking water at the arsenic safe well is tiring or not tiring?

1 ¨ Not tiring 2 ¨ A little tiring 3 ¨ Quite tiring 4 ¨ Tiring 5 ¨ Very tiring

Advantages:

  • Precise and explicit responses
  • Easy and quick to gather
  • Easy to compare and analyse
  • Easy to report

Disadvantages: unknown responses or aspects are not detectable.

Box 2.2.3: Instructions for the supervisors during data collection

  • Organize transport, food, and accommodation for the team.
  • Facilitate contact with the communities.
  • Help the data collectors to find households.
  • Verify that households are correctly selected, e.g., that not only people are selected that perform the target behaviour.
  • Check that participants are handled respectfully and informed consent procedures are implemented (i.e., participants can refuse to participate and/or receive all information related to their participation)
  • Motivate the data collectors, e.g. by giving positive feedback.
  • Check that the interviews/observations are conducted according to instructions, e.g. by surprise visits.
  • Check each survey instrument for missing data, e.g. if necessary, send data collectors back for completion.
  • Check each survey instrument for inconsistencies in responses; these could indicate a misunderstanding of a certain question or a typing error by the data collector. If necessary, discuss these with the data collectors and clarify misunderstandings.
  • Give data collectors’ feedback on their use of each survey instrument.
  • Arrange short daily team meetings to discuss possible problems, to answer questions and to give feedback on the completed questionnaires. It is important to maximize the consistency of the data collection procedure between data collectors.
  • Number the survey instruments consecutively with a household ID number. This number replaces the identification information (e.g. name of participant and of her/his father) in the data file to ensure the survey’s confidentiality.
Advantages of appointing health promoters as data collectors:
  • No recruitment necessary
  • They know the projects
  • We know them already
Disadvantages of appointing health promoters as data collectors:
  • It may be difficult for them to change from the role of health promoter to that of an objective data collector who exerts no influence. This is especially true during the survey after the intervention.
  • Participants may be inclined to distort their responses to please former promoters with exemplary answers. Again, this is especially true during the follow-up survey.

Box 2.2.1: Instructions for sample size calculation and sample selection procedure

Sample size calculation

To define the sample size, we need to obtain information on population figures in the project region. Usually, the key figure is the number of households. We need information on the number of households both across all project communities and for each community separately. We define the total sample size based on the total number of households across all communities. We suggest the following rules of thumb:

  • In general, survey 10% of the households.
  • Never survey less than 50, better more than 100 households.
  • Do not survey more than 1000 to 1500 households

To specify the sample size per community, we apply the same ratio as for the total sample size, usually 10% of the households. Never survey less than 10 households in a community. If we are not able to survey all project communities, we have to select some communities at random, for instance by lottery. The more communities that are surveyed the better.

If the project design includes an evaluation survey it is recommended to adapt the sample size to possible drop-out of participants.

  • If you plan to conduct the follow-up survey directly after the intervention phase, include at least 100, better 200 households.
  • If you plan to conduct the follow-up with a time-laps of 12 months, include 200, better up to 400 households.

 

Sample selection procedure

Whenever an exhaustive survey is not possible, we have to select the households to be surveyed. To achieve a representative, unbiased sample, we apply a random selection procedure. This procedure avoids the risk that data collectors select households based on opportunity, namely that they simply survey those households which are most easily reached or available; such an approach is especially prone to bias. There are several methods for selecting households randomly. Which method is most appropriate depends on the local conditions. Three methods are discussed here:

1) True random sampling:
  • Prepare a list of all households within a community.
  • Select the households to be surveyed randomly, e.g. by throwing a coin or using a random number drawing program.

Note: True random sampling is the best sampling strategy. However, a complete household list is a prerequisite for this method.

2) Random route sampling for a team of 10 data collectors:
  • Map the community together with locals.
  • Select 10 crossroads randomly.
  • For each crossroad, select one side of the road randomly.
  • Appoint a data collector to that side of the road.
  • Have the collector survey every third household (or another fixed regular interval) on that side of the road.
  • If the target person is not at home or the household refuses to participate, note the absence or refusal to participate, skip the household, and select the next household in which the target person is at home.
  • Afterwards, continue selecting every third household.

Note: Apply random route sampling whenever a list of households is not available but the community is clearly structured by streets.

3) Clustered random sampling for a team of 10 data collectors:
  • Map the community together with locals.
  • Group the community into clusters and select 10 clusters randomly.
  • In each cluster, select one household randomly.
  • Appoint a data collector to a household selected.
  • Have the collector start with the appointed household.
  • Afterwards, survey every third household (or another fixed regular interval) when walking in a circle to the left.
  • If the target person is not at home or the household refuses to participate, note the absence or refusal to participate, skip the household and select the next household in which the target person is at home.
  • Afterwards, continue selecting every third household when walking in a circle to the left.

Note: Apply clustered random sampling whenever a list of households is not available and the community is not clearly structured by streets.

Box 3.5.: Interpretation of results

FactorItem / Questionmean valuedifferenceinterpretationdecision
Behavior: chlorinationHow much of your household’s drinking water do you chlorinate?Doer: 93%
Non-Doer: 54%
40%Doers chlorinate 93% of their drinking water on average, whereas non-doers only chlorinate 54% of their drinking water.selected for the intervention
health knowledgeI will present you some potential causes of diarrhea. Could you please tell me for each whether it is a cause of diarrhea or not?Doer: 2.4
Non-Doer: 2.3
0,1Doers and non-doers do not differ strongly in health knowledge.not selected for the intervention
other’s behaviorHow many people of your community chlorinate all their drinking water?Doer: 3.1
Non-Doer: 1.6
1,5Doers perceive more that others in their surrounding also chlorinate their drinking water.selected for the intervention
action controlHow keenly do you try to chlorinate all your drinking water?Doer: 2.7
Non-Doer: 1.3
1,4Doers more keenly try to chlorinate all their drinking water.selected for the intervention
reason 1: good motherWhat are your reasons to chlorinate your drinking water?Doer: 70%
Non-Doer: 30%
40%70% of the doers mention that a reason why they chlorinate their drinking water is beca