Creating Demand in Public Health

Amina Tarraf


"This report demonstrates how behaviour change communications [BCC] is key to improving public health in developing countries. Whilst building infrastructure and services is critical, there is also a need to change social and behavioural norms to create the demand for public health services."

This study from the WPP Government and Public Service Sector Practice website brings field work, qualitative research, and desk research to bear in this case study of behaviour change of open defecation (OD) in India through demand creation. The project "follow[ed] a four-step process to develop an effective social and behaviour change strategy. The process is based on UNICEF guidelines and Thompson Social|J. Walter Thompson’s proprietary tools."

The steps are (listed in the document with corresponding questions): problem analysis; behavioural drivers and barriers; communication objectives; and communication strategy. The study found that key to breaking the inter generational cycle was developing habits among children of using latrines or toilets. In order to do so, "[t]he strategy is to use communications to create a new social norm that open defecation is dirty, disgusting and bad for children’s health."

The study gives and analysis of OD behaviour, a description of the work of Swachh Bharat Mission (Gramin) (SBM-G): "the challenges that the programme faces in enabling sustainable rural sanitation, a detailed analysis of the key stakeholders and beneficiaries, and the roles of key players in the communications process." In the final section, it gives recommendations on a BCC strategy.

In the analysis of the situation in India where literacy, access to water, and poverty were not found to be barriers, a study found the need for: demand for latrines; a change in the perception that latrines are a luxury; more ultilisation of government-built latrines; a change in choice of OD, rooted in culture; and a change in perception of odor and need to empty the latrines. Perceived advantages of retaining OD among the population studied included: pleasure and comfort of OD; association with healthy habits like rising early; lack of recognition of health threat to children; and an association with purity in the Hindu religion. Challenges include: scale, population density, and low demand.

Previous efforts are analysed including government efforts and Swachh Bharat (see related summaries). Stakeholders are seen as men, women, adolescents, elders, and children. Administrators include officials and committees at the national, provincial, district, and village level. “Influencers include PRI/Village Heads, religious leaders, local leaders, doctors, SHGs, Youth Groups, headmasters, schoolteachers and children." Advocates include policymakers, development agencies, media, businesses, and civil society.

The communication strategy is to :"Create an environment where toilet construction and regular usage is viewed as virtuous and progressive. Ensure people appreciate the importance of latrine use, so that it ultimately becomes the norm and the habit." The primary audience is parents of children 0-6 years old, who are also the beneficiaries, along with adolescent girls who expressed a demand for latrines. The secondary audience is the opinion leaders and influences, and the tertiary audience is service providers/ advocacy groups. Current behaviours are classified among: non-users, sporadic users, and lapsed users. The desired outcome is demand leading to construction, regular use, and maintenance.

Tools to communicate messages of disgust linked with child and community health include: 

  • in general, interpersonal communication training and capacity building
  • for the primary audience, TV - including series, radio, theatre, street folklore, posters, Bollywood type movies, and newspaper
  • for the secondary audience, communication at village congregation points including wall painting, billboards, etc.
  • for advocacy groups, websites, posters, magazines, person-to-person contact, workshops, mobile messaging, media packages, training manual for opinion leaders, and events.

Tools for communicators are charted and include audio visual materials,  flip books leaflets, scripts for performance, guides, posters,and demo devices. For children, materials can include activity sheets with games, puzzles, quizzes, slogan writing, and song creation, colouring books, and plays. Community events can include speeches, ;movies, plays, street performance, and children's rallies and marches. The conclusions recognise the complexity of the issue in India and the potential for BCC through various channels.


WPP website, February 1 2017.