Habits are behaviours that are performed frequently and automatically in response to cues. 

Many researchers have proposed that automatic performance in response to environmental or situational cues is the active ingredient of habit formation. Taking the example of handwashing with soap, potential cues could be the perception that hands are dirty (environmental cue) or an association with a particular action (situational cue) such as feeding a baby or exiting the toilet after defecation. A handwashing habit is formed when a person automatically washes their hands in response to these cues. A hygiene promotion (HP) assessment should try to identify the cues that can be used to support sustained behaviour change.

There are two main challenges faced by HP in promoting habit formation. Firstly, there may be existing habits that conflict with the new habits, for example, a person might return directly to household work after using the toilet - without washing their hands. Or a person might wash their hands whenever it is time to feed the baby - but without soap. In such situations, it is essential to remove or change the cues that trigger the old, undesired habit. Small modifications to the environment, such as a reminder to wash hands when exiting the toilet or a soap dish or mirror above a basin, may serve as cues for the desired new behaviour and help to encourage it. Major disruptions in the environment during an emergency can remove existing cues; so can constructing a new latrine, moving house or the changes associated with the seasons. 

The second challenge is that habit formation requires a stable environment and sufficient time (up to several weeks for a behaviour that is executed daily). A stable environment is needed because the cues must be the same over time to automatically trigger the desired behaviour. Time is necessary because the execution of the behaviour in response to the cue needs many repetitions to become automatic. It is not therefore always possible to alter existing cues or to establish new ones. In such situations, self-control, which requires substantial effort, might be the only strategy available to create a new habit. Facilitating support from others T.46 can be an important way of supporting an individual’s self-control in such situations. Rewards and Incentives T.40 may also be effective, compensating the participants for the additional cognitive effort required for self-control.

Emergencies provide opportunities as well as threats for habit formation. On the one hand, existing habits are already disrupted: individuals have been displaced, live in a new social setting and are obliged to change or modify their usual everyday activities. This can make the formation of new habits much easier. On the other hand, the environment might continue to be volatile, preventing new habits from being established. 

Process & Good Practice

• Use changes in the context to support behaviour change: context changes such as seasonal changes, marriage, illness and the construction of major infrastructure or displacement are likely to have disrupted existing habits. Aligning behaviour change interventions with these disruptions can make it easier for individuals to establish new habits.

• Piggyback on existing behaviours: the newly promoted behaviour can be absorbed as an add-on to activities that are already performed. For example, if individuals already store designated drinking water in a particular place, storing chlorine tablets in a nearby visible location can prompt people to chlorinate water directly after collection.

• Add friction to the undesired behaviour: weaken existing habits by restructuring the environment to disrupt the smooth performance of the undesired behaviours, making them more difficult to do and creating an opportunity to establish new ones. For example, removing drinking vessels from the location where unsafe water is stored and locating them exclusively where safe water is stored may disrupt the existing habit of consuming unsafe drinking water and foster a new habit of safe water consumption. 

• Target and plan specific activities to change behaviour: the desired behaviour must be performed repeatedly in response to the same situation to become a habit. Planning should specify the exact situation (for example, household water treatment), when it occurs and where and how to perform the desired behaviour. For example, a type of planning called daily Routine Planning T.42 could be used to promote household chlorination. The person would be asked to plan exactly when (how long before drinking?), where (what water container?) and how (dosage?) they would take the specific steps to chlorinate water in the course of their daily life. 

• Encourage (self) monitoring of behaviour: to successfully change behaviour and avoid falling back into old, conflicting habits, participants may need to monitor themselves. This is particularly relevant if cues for conflicting habits cannot be removed. Self-monitoring can be achieved by inviting participants to record their behaviour. For example, participants could tick on a chart each time they chlorinate their water. 

• Use memory aids and environmental prompts: memory aids can remind individuals of the desired behaviour in situations when they are at risk of relapsing into old habits. A reminder poster placed where the water collection containers are stored could, for example, remind participants to collect water from the safe source. Similarly, posting an action plan for chlorination on the wall could serve as an effective environmental prompt.