Water and Handwashing in a Drought-Prone Region of Southern Niger: How Environment, Household Infrastructure, and Exposure to Social and Behavior Change Messages Interact

Under-5 mortality rates are extremely high, and Niger has the third-highest mortality rate for diarrheal disease in children under 5, linked to poor household water, sanitation, and hygiene (WASH) practices. Efforts to prevent diarrheal disease, particularly in children, include promoting handwashing with soap and water at key moments. Social and behavior change (SBC) is a key strategy to promote and improve adoption of healthy behaviors, including proper hygiene. The goals of SBC are to increase knowledge, address attitudes and perceptions, and determine barriers to uptake of the behavior. SBC approaches have been shown to improve WASH outcomes, but environmental conditions can lead to reduced effectiveness. In a region reliant on livestock and agriculture, water for handwashing and sanitation may not be prioritized when it is needed for drinking water, livestock, or supporting agriculture. The United States Agency for International Development (USAID) Resilience in the Sahel Enhanced (RISE) initiative was developed in 2012 to strategically layer and sequence humanitarian assistance while reducing vulnerability to shocks, including drought, in regions of Burkina Faso and Niger over 5 years. In 2018, the USAID introduced RISE II with the aim of advancing the RISE initiative by incorporating best practices and lessons learned to address several key areas, including elevating water security and focusing on targeted areas for joint action between health programs and infrastructure development aimed at increasing water availability. A critical component of RISE II was the introduction of an integrated SBC strategy that aimed to provide messaging across sectors to maximize contact with key audiences to promote a set of behaviors more efficiently. With the introduction of a multisectoral approach, the USAID aimed to leverage knowledge, expertise, reach, and resources from partners and sectors to benefit from their combined and varied strengths as they worked toward the shared goal of producing better health outcomes. Previous research has found that behavioral determinants such as access to soap and perceived self-efficacy to practice handwashing are barriers to behavioral adoption. However, although there has been an increased focus on assessing how to best leverage multisectoral efforts, few studies have identified how best to provide messaging relevant to several sectors. This study aims to assess how three measures of drought relate to household water availability at handwashing stations, a behavior addressed by SBC activities, and knowledge of key handwashing moments, a behavioral determinant. A quantitative survey was administered by trained staff in April 2021 with households in the Maradi and Zinder regions of southern Niger. Within each region, the USAID RISE II program implements multisectoral activities in 18 specific communes within five departments (administrative areas), led by three different RISE II resilience food security activities (RFSAs). For this study, 12 communes were sampled from comparison communes based on similar sociodemographic characteristics, population density, and healthcare accessibility. The study applied a three-stage stratified sampling procedure. In the first stage, six intervention communes and six comparison communes were randomly selected. In the second stage, all enumeration areas (EAs) identified in the 2012 general census by commune in each of the randomly selected communes were listed. Then, probability proportional to size was used to select EAs per commune starting at a random point and then systematically selecting areas using a fixed interval. A total of 2,708 households were surveyed, and household data were integrated with two local environmental measures: 1) water level at the nearest waterhole point, and 2) anomalous rainfall for the previous rainy season derived from climate hazards infrared precipitation with station rainfall (CHIRPS) data. Logistic regression models were constructed to explore how environment, household infrastructure, and exposure to SBC messages were associated with two hygiene-related outcomes: 1) observed water and soap available at household handwashing stations, a behavior, and 2) knowledge of critical moments for handwashing, a behavioral determinant. The results showed that households near a water point with higher water depth were statistically significantly more likely to have water and soap observed at the handwashing station. Women in households near a water point with increased water depth were more likely to know three or more critical handwashing moments. Exposure to messages about the importance of handwashing was significantly associated with knowledge of critical handwashing moments and having water and soap observed at a handwashing station.