Emerging from shadows: Insight on tropical disease

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When we ask research participants about personal aspects of their lives, and when we expect instant self-examination of their behaviours, how confident can we be about the level of accuracy and the completeness of their responses? This perennial question is what has driven the development of behavioural insight shadowing (BIS), a bespoke and adaptive approach in the qualitative research of behaviour change, within the Ascend West and Central Africa Programme. This aimed to prevent neglected tropical diseases (NTDs) through effective behaviour change communications (BCC).

The objective of the research was to generate in-depth, culturally specific audience insights. In late 2019, M&C Saatchi World Services adapted the typical ethnographic approach to deliver real-time insights about the attitudes and behaviours of those most vulnerable to NTDs: farmers, fishermen, and families with limited water and facilities. The research locations included urban, semi-urban and rural households in NTD-endemic areas of Nigeria, Guinea-Bissau and the Democratic Republic of Congo. The mixed-method approach included BIS and a large-scale household survey, plus 36 focus groups conducted across the three countries.

Behaviour settings

BIS is underpinned by ‘behaviour settings theory’ as a framework, which considers that all behaviours occur in a setting with distinct components, such as the props, the routine, the norms and the competencies, to name a few. BIS methodology, as used in this project, involved a whole-day observation of household activity. The observation ended with an in-depth interview with participants to discuss and validate the accuracy and normalcy of observations, review and reflect on behavioural drivers, and address potential bias.

African researchers from research organisations MRS Nigeria and Market Liaison were trained in the BIS approach and helped improve operational delivery, ensuring that local languages and cultural norms were understood, specifically the etiquettes of visiting participants’ homes and navigating access to small communities.

Opportunities for change

BIS methodology produces ethnographic stories – research outputs that are anthropological and graphic in nature – and qualitative data that complements mixed-methodology approaches. Cultural insights are then used for more impactful BCC interventions that lean into existing norms where possible, improving the applicability and sustainability of BCC messages.

BIS findings highlighted the importance of gendered behaviours relating to water, sanitation and hygiene (WASH), as well as the ways in which health messages were accessed via local media and local influencers. Findings also identified specific opportunities to impact on behaviour change.

For example, nearly all survey respondents responded that hand washing was important, but BIS observations aided an understanding of a hierarchy of importance when soap, water or time was limited. This prompted BCC messaging that aimed to shift the hierarchy towards the prioritisation of disease prevention.

Women drive the household WASH routines: they make daily decisions about how water is used in the home, they direct children to wash hands and fetch water, and they do the cooking and cleaning. BCC that speaks to their role and sense of responsibility is paramount.

The study found that WASH routines, dining routines and religious adherence are temporal: taking place at the same time of day, every day, presenting an opportunity for messages that chime with established routine.

Many WASH activities involve social interaction: during outings to local water sources, participants encounter influencers, such as pastors and imams. These familiar and respected voices can effectively spread health messages and endorse social change.

BIS adds value by helping to identify and understand the cultural contexts in which daily behaviours occur, and can help develop culturally appropriate BCC. Moreover, it is important in determining whether such intervention needs to be in alignment with everyday routines and attitudes – or in disruption of them.

• Neglected tropical diseases (NTDs) affect more than 1.5 billion people globally (M&C Saatchi, 2019 )
• 40% of people with NTDs live in Africa (M&C Saatchi, 2019 )
• Improved hygiene practices can reduce the chances of an NTD infection by 70% (WaterAid, 2015 )

Sherrelle Parke was, until recently, a senior research manager at M&C Saatchi.