Child washing hands in Nepal

The beauty of truly listening

Tom looks at how a behaviour science tool developed 30 years ago can help the world fight COVID-19.

By Tom Davis

A mother in Bolivia doesn’t take her child for growth monitoring.  A sugarcane cutter drinks water from an irrigation ditch that is likely contaminated. Children in a Nepali school don’t wash their hands with soap despite there being a handwashing station there.

Can you guess why each of these things might occur? Maybe the mother doesn’t think it’s necessary? The sugarcane cutter is just too tired to purify the water? The children haven’t heard the benefits of hand washing?

We need to stop guessing. Don’t assume. Be sceptical. If I know anything from working in public health around the world for more than 35 years, it’s the answers to those questions will be very different depending on the country, the culture, and the community … and often quite surprising!

I was born in Virginia, lived the majority of my life in North Carolina, and now reside in Geneva, but it was a conversation while living for four years in the Dominican Republic that changed the course of my work and life.

It was 1990, I was working with an extremely marginalised and exploited group, Haitian sugarcane cutters, who were struggling to access clean water and were being ravaged by diarrhoea, cholera and other waterborne diseases, killing many children. I had a heart for the Haitian people after working in Haiti in the early 80s, living in a Haitian village, and speaking their language fluently. I did not start with Barrier Analysis. I talked to Haitians there, read ethnographies and books on the Haitian people living in the DR and their situation there. Then I asked my Dominican colleagues why they thought the Haitians were not treating their drinking water in the camps. They gave answers I had heard before – “they haven’t heard the message often enough”, “they’re lazy” among others. I knew from my public health training and from years of living in a Haitian community that most people in Haiti are quite smart, extremely hardworking and pragmatic … I mean, could you survive on less than $2 a day? No, there was a bigger story, and we needed to really listen to people before we jumped to conclusions about how to help them with the problems they were facing. 

I suggested we go talk to them, and that we structure our questions around what we know influences health behaviour. We asked questions based on twelve potential drivers of behaviour from the Health Belief and Theory of Reasoned Action behaviour models that I had learned about in public health school. And, as so often happens when you ask rather than assume, we found the answers to be very different from what my colleagues had expected, and quite surprising. For example, they were told to use 5-10 drops of bleach per gallon to purify water – but no one had gallon containers, they just had five-gallon jerry cans to fill 55-gallon drums where water was added and removed daily. The general recommendation (“per gallon”) was not very helpful, and unless you are very good with calculus, good luck in trying to titrate the right amount of chlorine to add to the drum every day. (Given that, we began promoting the addition of 25-50 drops of bleach to each jerry can and then pouring that into the drum.) Due to their poverty, they could only afford to buy bleach in little baggies from the camp stores, not in the big bottles that we often buy. However, they knew they were being cheated – the opened bottles were being watered down by the store owners to make more money. (Given that, we had Health Promoters begin to sell bleach in small quantities, since they were more trusted.) They heard rumours that chlorine turned your skin white. The camp guard would not provide them with drinking water in the fields, and they did not own smaller containers like canteens, so that’s why they drank from the irrigation ditches during the day. They also did not believe that the water in the camp was contaminated.  When we asked them what it would take for them to believe their water was not purified, their suggestion was quite scientific:  they said they would need to have it tested by both a government and a private laboratory. So that’s exactly what we did.

These families were exploited at every turn.

Through their eyes and words, we grew to have a much richer understanding – not just of this water purification behaviour, but of their entire life situation in the camps, the abuses they experienced, and some possible solutions.  BA helped us to answer the question, “what is going on here?” – not just regarding the behaviour we studied, but a better view of the entire system. And it was one of the motivations that we began quietly documenting human rights abuses in the camps that led to real changes for the people there.

And so the Barrier Analysis method was born. BA gave us a more humanising view of the lives of people we were trying to help, and showed what we get wrong when we guess about people’s behaviours and motivations. I may be a bit biased, but I love this tool – it’s not that hard to use, it is easy to teach, and it gives you nice scientific findings without having to have a statistician and researcher on staff.

Seeing things from other people’s points of view is a beautiful thing. We are being reminded of this a lot, sometimes painfully, at the moment. People’s sources of information polarise us, and rumours and misinformation fly at unimaginable speeds, so persuading people to adopt behaviours that are good for their health and well-being, and that of their families and communities, starts with really listening to people.

These days, hundreds of Barrier Analysis studies have been done by more than 30 organisations and agencies in more than 30 countries. It looks a host of behavioural determinants including perceived social norms (who approves and disapproves of the behaviour), perceived self-efficacy (the belief that one can do the behaviour if one wants to), perceived divine will (whether people believe that God [or Allah or the gods] approves of one adopting the behaviour), perceived risk (such as the risk of getting COVID-19), and perceived severity. Nowadays we also quantitatively compare the responses that the “Doers” and “Non-doers” give during BA, and that helped us to be sure the differences that we are hearing are real ones. It’s a goldmine of information, and will be vital in our work to end the COVID-19 pandemic more quickly. 

A number of my colleagues around the world and I are doing Barrier Analysis studies right now on COVID-19 vaccine acceptance and regular mask usage. So far, the results from our Bangladesh and Myanmar vaccines studies are – you guessed it – a bit different from what was expected and surprising. For example, in Tanzania, vaccine acceptors are five times more likely [than non-acceptors] to say that they fear becoming impotent if they get a COVID-19 vaccine, and in Kenya, acceptors were more than twice as likely to believe that it would be “very serious” if someone in their household got COVID-19. As we examine the results from Bangladesh, India, Myanmar, Kenya, Tanzania and the DRC, and we begin sharing the findings with WHO, GAVI, and UNICEF, we are finding that more and more colleagues around the world are interested to do their own BA studies, to listen to the communities that they serve. This sort of focused listening with BA, combined with other more qualitative methods like focus groups, will help us to really understand and address people’s concerns about getting the COVID-19 vaccines, and to assure that people that they trust (such as faith and community leaders) will lead the way in providing accurate information about the vaccines.

In Bolivia, the mothers that didn’t take their children for growth monitoring had heard that malnutrition was a serious problem.  But when we probed, “How serious is it, more than measles?” No, not at all. “Flu?” No. “What about having a cold?” No, having a cold is more serious than having malnutrition. If a mother believes that, we need to start by convincing her of the danger of a child becoming malnourished rather than just telling her that it’s the right thing to do to take her child for growth monitoring.

In Nepal, many children had heard that they should wash their hands. But like many adults, they simply often forget, and sometimes people take the soap. (Adding mirrors to the hand washing station, painting footprints from the latrine to the station, and using soap on a rope helped there.)

The words from Isaiah 65:20 that first inspired me into this work – “Never again will there be in it an infant who lives but a few days or an old man who does not live out his years” – motivate me today as much as they did when they first leapt off the page of a Bible years ago. We can face down COVID-19, we have the tools, we just need to find the will. And really listen to people as we face this together.


Tom Davis is World Vision’s Partnership Leader for Health and Nutrition. Follow Tom on Twitter @ ThomasPhilipDa1