Education for Sustainable Development (ESD) plays a key role in achieving the Sustainable Development Goals. However, the implementation of ESD in education remains a challenge, particularly for countries such as Madagascar. ESD needs to consider regional realities to be relevant to learners. An expert study identified health and land-use courses of action for regionally relevant ESD in northeast Malagasy primary education. However, what about teacher perspectives on the possibilities for implementing such courses of action? The present think-aloud study with 10 Malagasy primary teachers used the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) to analyze factors that teachers perceive to be relevant for implementing health and also—as an innovation—land-use courses of action. The IBM-WASH model is a tool for identifying opportunities and barriers to a desired health behavior. It turned out that the local school’s surroundings, shared values and attitudes, and existing habits are important for implementing health and land-use courses of action. Therefore, regionally adapted health and land-use teaching should consider community-contextual, community-psychosocial, and habitual-psychosocial factors. Additionally, teachers mentioned the costs and benefits of land-use practices. Thus, land-use teaching should take the individual-technological factor into account. This paper argues for a regionally adapted ESD in teacher and school education.