In low- and middle-income countries (LMICs), the presence of an informal economy can lead to human exposure to toxic metals such as lead (Pb). This paper demonstrates the local health and economic benefits of modifying practices within the informal economic sector in Madagascar. Specifically, leaded components in 504 locally manufactured household water pumps were replaced with unleaded components. Prior to the intervention, 32% of the household systems exhibited lead concentrations above the World Health Organization (WHO) provisional drinking water guideline of 10 μg/L, but after the intervention, fewer than 3% of the systems were in exceedance. The reduction of lead concentration is modeled to reduce the fraction of children with elevated BLLs (>5 μg/dL) from 34 to 13%. The reduction in BLLs is estimated to provide an average economic benefit of US$11 800 per child based on predicted increases in lifetime productivity. This corresponds to a total benefit of US$8.7 million for the 730 children aged 1–5 associated with the pumps, representing a return on investment of greater than 1000-to-1. Results demonstrate how the formation of partnerships between public, private, and civil society entities, as suggested by UN Sustainable Development Goal 17, can realize important local economic and health benefits in LMICs.

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Lead (Pb) exposure through water contamination is an important issue at the intersection of public health and water, sanitation, and hygiene (WASH). Behavior-change programs designed to address this pressing problem rarely take a behavioral-science-informed approach, nor do they consider the role of intermediate players who often influence and support behavior change. Social marketing segments the population and focuses on the consumer/user throughout program development and implementation. To illustrate the social marketing process, this cross-sectional, qualitative design study investigates the use of Pb in the construction and maintenance of household pitcher pumps for potable water in Madagascar. A sample of 18 technicians were interviewed on their current practices, motivators, barriers, and communication channels for knowledge exchange. The results reveal the importance of peers, those considered experts or “market mavens”, and the need for information on the dangers of Pb as an outdated practice for any future intervention. This study advances the notion of a design shift within engineering WASH projects, whereby social/behavioral approaches are used to consider the needs, concerns, and current behaviors of the consumer. We also advocate for engaging intermediate players who often influence behavior change in the rollout of an engineering innovation.

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Background and Situation Analysis The importance of Water Sanitation and Hygiene (WASH) projects for the protection of health is embedded in the sustainable development goals. However, within the development and humanitarian fields sustainability of WASH projects is still a challenge with 30–50% of projects failing within two to five years of implementation. Though failure is not linked to any one source, a common theme speaks to a greater need for community engagement and integration of the wants and needs of the end-user in the design process. Social marketing, with its focus on the consumer and use of commercial marketing strategies to achieve behavior change is a promising approach that can be integrated into ongoing WASH initiatives to meet program outcomes and to achieve long-term sustainability. Priority audience Primary audience includes technicians who manufacture and repair pitcher pumps. Secondary audience includes community members in Toamasina, Madagascar, who will experience a decrease in exposure to lead through their water supply. Behavioral objectives Decrease exposure to lead (Pb) introduced through the use of a decentralized, self-supply water system, the pitcher pump. Specifically, decrease use of leaded components in the manufacturing and repair of pitcher-pumps Strategy/Intervention Development of the intervention followed the social marketing process including conducting a situational analysis, identification and selection of a behavioral focus and priority population, formative research, development of an integrated marketing strategy, pretesting the strategy, followed by campaign implementation, and monitoring and evaluation. An intervention focused on building a sense of community and introducing the element of professionalism for the pump manufacturers was developed, consisting of personalized one-on-one outreach to raise awareness of the health topic, followed by skill building trainings on how to make the switch to non-leaded components. This was coupled with tangible products that created a new professional network, documentation of work, and backing of work by trusted government entities. Evaluation Methods and Results Using the theory of planned behavior, a pre/post-test summative evaluation was developed. Preliminary results indicate that pump technicians no longer use lead in pumps unless specifically requested by the pump owners. These results indicate a positive shift towards the use of lead-free components with project follow-up and analysis ongoing. Recommendations for Social Marketing Practice Use of social marketing within the WASH sector is lacking. This paper demonstrates the integration of social marketing in an ongoing WASH project. Through a description of each step of the process, our experiences in implementing it and the lessons learned, we hope to guide future integration. Additionally, this paper demonstrates the convergence of engineers and social marketers working collaboratively on an interdisciplinary team and how this served to enhance project understanding, aid in building local partnerships and help with long-term sustainability.