What is a framework?
Behavior change frameworks are the bedrock of applied behavioral science. Designed by behavioral scientists for policy makers and industry leaders, these summaries of cutting- edge decision-making insights are essential for applying research in the public and private spheres. Frameworks distill strategies for influencing human decisions into simple, portable mnemonic devices or acronyms. You might think of them as secret keys that allow us to access complex ideas, which makes it possible for theoretical insights about how people think and act to make their way into the practices of organizations across every industry and environment. To understand more about how these frameworks work in practice, check out our case studies.
Theory, meet practice
TDL is an applied research consultancy. In our work, we leverage the insights of diverse fields—from psychology and economics to machine learning and behavioral data science—to sculpt targeted solutions to nuanced problems.
The Basic Idea
In much of the world, we take for granted our access to effective sanitation. A clean bathroom with proper plumbing is so commonplace that it can be a bit hard to wrap our head around the fact that this is not the case worldwide. Around 2.5 billion people do not have access to basic sanitation services, negatively impacting their health, as well as their economic and social well-being.1
While increasing the availability of basic services and products is one way to battle the issue at hand, changing people’s behavior is equally important. Through behavioral changes, we can ensure there are long-term improvements to sanitation around the world.
Before we can improve sanitation behaviors, we must first understand them. The SaniFOAM framework is a conceptual behavior change framework used in community-led and external marketing approaches.1 The “FOAM” acronym helps us focus on four key elements of sanitation behaviors that can inform the design of effective programs: F for Focus, O for Opportunity, A for Ability and M for Motivation.
Behavioral Determinants: The O, A, and F, of the SaniFOAM framework are known as behavioral determinants. These factors determine whether a behavior is adopted. The three determinants chosen for the sanitation framework adhere to a classification system commonly used in fields where organizations attempt to influence consumer behavior.1
(F)ocus: narrowing down what kind of behaviors need to change, to improve sanitation processes is the first step. A particular target population is also identified at this stage to ensure proposed strategies will be effective for this group.1
(O)pportunity: Does the individual have the chance to perform the behavior? Determining the answer to this question includes examining access, social norms (would they be regarded poorly if they behaved differently), whether there are sanctions for exhibiting the behavior, and what the quality and attributes are of the sanitation service or product.1
A(bility): Does the individual have the capacity to engage in different sanitation behaviors? This element is further broken down into five determinants:
- Knowledge: Awareness of sanitation services and skill required to be able to use sanitation services or products.
- Social support: the physical and emotional comfort given by one’s community which helps individuals adopt new behaviors.
- Self-efficacy: believing that one can execute the behaviors makes them more likely to engage in them.
- Roles and decisions: being aware of who in a household or community usually makes the decisions when it comes to sanitation behaviors is important to hone in on strategies focused on these individuals.
- Affordability: it is usually in developing countries where sanitation services are lacking, which means that affordability is an influential factor on whether particular behaviors are adopted. Affordability encompasses money, time, and resources.1
M(otivation): multiple factors determine whether an individual is motivated to engage in sanitation behaviors. They can be broken down into six categories:
- Attitudes and beliefs: these determinants relate to an individual’s perception of sanitation behaviors and related services and products.
- Values: these are related to beliefs, but unlike attitudes and beliefs that operate on an individual level, values operate at the collective level. Communities usually hold collective values about which sanitation behaviors are desirable.
- Emotional, social and physical drivers: strong internal thoughts and feelings that motivate behavior. An example is that you eat because a physical need motivates you to.
- Competing priorities: while some communities might be open to the idea of new and improved sanitation behaviors, they might need to spend the money elsewhere.
- Intention: people tend to follow through on behaviors if they have a plan to do so.
- Willingness to pay: this determinant is related to competing priorities, and examines how much and for what individuals are willing to pay. 1
Improving sanitation behaviors in developing countries has been a priority for years. Traditional approaches focused solely on ensuring the appropriate resources were available to all, but these approaches were ineffective. It became clear that merely providing sanitation services and products is not enough to enact meaningful change in behavior, and before changing the reality of the situation, we must first understand why the situation exists.
In 2008, at a workshop hosted in Durban, South Africa, participants from six health and hygiene organizations got together to develop the SaniFOAM framework. Some of these organizations included representatives from UNICEF, the London School of Hygiene and Tropical Medicine, USAID, and AED/Hygiene Improvement Project. It was organized by the Water and Sanitation Program (WSP).2 Participants took inspiration from another conceptual framework, PERForM, used by Population Services International to guide research into the relationship between behavior and health.3
Once developed, the SaniFOAM framework was applied as part of the WSP’s Global Scaling Up Sanitation Project, with the hopes that the new approaches would improve rural sanitation at a larger scale. Initially, the project focused on rural communities in three countries: Tanzania, in ten different districts, Indonesia, specifically East Java, and in India, in Madhya Pradesh state and Himachal Pradesh state.1 The WSP worked closely with local and national governments, non-governmental organizations, and the domestic private sector and continues to do so across even more countriessanitation.4
The aim of the framework is to help individuals and households move up what is known as the sanitation ladder. It hopes to move people from the bottom ranks of the sanitation ladder, which includes behaviors like open defecation, a bit further up to the use of simple latrines, and eventually, to the top of the ladder where individuals use toilets connected to a sewage system.1
The framework was a catalyst for in-depth, focused, and useful research into sanitation behaviors that has allowed for tons of qualitative and quantitative data to be collected about the behavioral determinants behind sanitation behaviors. It has informed many strategies to improve sanitation behaviors in developing countries.
The SaniFOAM framework helps project managers better understand and explain sanitation behaviors of target populations. It provides a clear foundation that outlines how to tackle sanitation behaviors, helping those involved in the project focus their interventions and inform the development of the program.1
It is a holistic framework that reflects that sanitation behaviors do not exist in isolation — they are connected to a range of behavioral determinants that are at the crux of enacting change. Using the SaniFOAM framework gets us closer to significant and sustained sanitation coverage.
The SaniFOAM framework is useful when initially planning a strategy to help communities improve their sanitation levels. However, viewing the sanitation life-cycle as a ladder suggests there are discrete stages that individuals can move up to, so long as the behavioral determinants are tackled first. Yet, the movement from one stage to another might not be as linear as SaniFOAM suggests. In a 2021 article in the Water and Health journal, authors Kopal Khare and Lavanya Suresh suggest there are multiple stages of the sanitation life-cycle: acceptance, construction, utilisation, maintenance, and safe disposal. Yet, the SaniFOAM framework does — similarly to this approach — understand that mere access to sanitation services is not enough to move individuals from one rung to the next.5
Using the SaniFOAM Framework as an analysis tool
Many researchers have used the SaniFOAM framework to analyze what kind of sanitation programs are effective and to better understand the behavioral causes behind sanitation practices. The WSP conducted a study that reviewed qualitative research reports between 2006 and 2012 from Cambodia, India, Indonesia, Kenya, Malawi, Peru, Tanzania and Uganda to explore how data from interviews, focus group discussions and questionnaires could be divided into the SaniFOAM framework. As such, it sought to create a thematic ordering and interpretation to identify factors that either positively or negatively influence sanitary behaviors.6
In opportunity, they found the main barriers to healthy sanitation behaviors were access to latrines (for example, farmers will often go in an open field as they do not have access to a nearby latrine), functioning latrines (seeing as these sanitation services are foreign to some rural communities, they were often found to be broken in some manner), perceived access of supply (the materials required for improved latrines are thought to be expensive and difficult to obtain), and negative perception of product attributes. Additionally, common social norms in these communities perceive open defecation as ‘natural’ and ‘practiced by generations’ which causes them to continue the behavior.6
For availability, the first category examined was skills and self-efficacy. The analysis found individuals in rural communities are relatively confident in their ability to build basic latrines, but less confident in their ability to build an improved latrine. Latrines are also seen as expensive to construct — these perceptions are not necessarily accurate because oftentimes, those unfamiliar with latrines are unaware of affordable latrine options.6
For motivation, the analysis found that some of the emotional, social and physical drivers that motivated people to use healthier sanitation services included a desire for comfort, having increased privacy, a desire to avoid embarrassment, and a desire for the social status associated with owning a private latrine. For competing priorities, individuals reported that other family expenditures like school fees, food, transport, and healthcare are higher priority than sanitation services. People prefer to spend their money elsewhere, especially since latrines are not seen as a good economical investment.6
The analysis of various projects on sanitation behaviors demonstrates that access to improved sanitation services alone will not lead to changes in sanitation behaviors. There are various social, economic and cultural drivers of behavior that are the root of individuals’ actions, which t need to be targeted.
Asan organization dedicated to uncovering the factors behind human behavior we too have conducted research onsanitation behaviors. Aerson, a Canadian non-profit organization and the Government of Nepal approached us to leverage behavioral insights to promote better sanitation practices.
We found that men use public toilets seven times more often than women in Nepal. In part, this might be explained by the social stigma surrounding menstruation. Women feel uncomfortable or embarrassed using public toilets while menstruating, while others avoid it because some communities prohibit women from using water sources during menstruation. Campaigns would have to focus on these cultural and social norms in order for Nepal to ensure there is gender equality in public sanitation practices.
The SaniFOAM framework realizes that to have a healthy society means understanding and nudging behavior accordingly. People don’t just automatically adopt new health behaviors because they are told to do so, as we have seen during the COVID-19 pandemic. In this article, our contributor Siddhart Ramalingam creates a checklist that could improve social instructions with regards to COVID-19 health measures and thus encourage more people to adopt the behaviors.
Washing your hands is always important, but it is especially important for healthcare workers that deal with open wounds, infected individuals and sick patients all day. We would expect healthcare workers to always be washing their hands, but unfortunately the number of hospital-acquired infections says otherwise. In this case study, The Decision Lab takes a look at how visual design cues helped nudge healthcare workers to wash their hands more often.
- Coombes, Y., & Devine, J. (2010). Introducing FOAM. Introducing SaniFOAM:A Framework to Analyze Sanitation Behaviors to Design Effective Sanitation Programs. https://doi.org/10.1596/27924
- Water and Sanitation Program. (2018). SaniFOAM: A framework to design effective sanitation programs. https://www.wsp.org/featuresevents/features/sanifoam-framework-design-effective-sanitation-programs
- Chapman, S., & Patel, D. (2004). PSI Behavior Change Framework “Bubbles”: Proposed Revision PSI Research Division. Population Services International Research Division. https://www.psi.org/wp-content/uploads/2004/10/behaviorchange.pdf
- Scaling Up Rural Sanitation. (2018). Water and Sanitation Program. https://www.wsp.org/global-initiatives/global-scaling-sanitation-project
- Khare, K., & Suresh, L. (2021). Justice and sanitation well-being: An analysis of frameworks in the context of slippage, based on findings from Shravasti, Uttar Pradesh, India. Journal of Water and Health, 19(5), 823-835. https://doi.org/10.2166/wh.2021.094
- O’Connel, K. (2014). What Influences Open Defecation and Latrine Ownership in Rural Households?: Findings from a Global Review. Scaling Up Rural Sanitation. https://www.communityledtotalsanitation.org/sites/communityledtotalsanitation.org/files/media/WSP_What_influences_ODandLatrine_Ownership.pdf