Monitoring Handwashing

Behavior

Jelena VujcicDept. of Social and Preventive Medicine

University at Buffalo, Buffalo, NY, USAjelenavu@buffalo.edu

Thursday, April 11th, 2013Monitoring Sustainable WASH Service Delivery Symposium,

Addis Ababa, Ethiopia

Overview

• Why monitor behavior? Shifting paradigm for handwashing programming and monitoring

• Current indicators used to measure handwashing behavior– Utility, strengths, limitations

• Measuring behavior at scale

http://www.unicef.org/wash/index_45948.htmlBen Nygren Pavani K. Ram

Handwashing promotion at a glance…

Major goals of handwashing promotion programs

A shifting paradigm in handwashing programming/implementation

Supply-driven

Infrastructure focused

Government and support agents as main drivers of change

Demand-driven

Behavior-focused

Room for private sector to respond to household demands

Government and support agents facilitate communities’ change process

…and a shift in monitoring methods and actors

van der Voorden, Keynote paper

Input Core human and financial resources required to develop the program for implementation

ex. Number of health workers hired

Process Activities and efforts implemented to achieve program goals

ex. Health worker visits to homes

Output Direct results of the efforts at the program level

ex. Number of soap bars distributed

Outcome Effects of program outputs at the population level

ex. Increased proportion of mothers who wash hands with soap at critical times

Impact Effects of program at the population level with adequate account of other factors

ex. Reduced risk of diarrheal disease

MonitoringMonitoring

Why monitoring handwashing behavior is important/relevant

Evidence from research Knowledge only Hardware only

• Old habits are hard to break, new habits are hard to make

Role of behavior in prevention, in health, in self empowerment, in equity is clear

• Without behavior do we have a complete picture of what the program achieved at the population level?

Necessary but not sufficient for practice

How is handwashing behavior measured?

IndicatorsGOAL

PROGRAMCOMPONENT INDICATORS DATA COLLECTION METHOD

Advocacy Outputs (A1) Number of handwashing promotion advertisements distributed/broadcasted(A2) Number of handwashing promotion events(A3) Number of participants at handwashing promotion event(s)(A4) Number of stakeholders introduced to benefits of handwashing with soap

Program records/Media trackingProgram records/MonitoringProgram records/MonitoringProgram records

Outcomes (A5) Recall of the event/advertisement(A6) Recall of the main message(s) from an event/advertisement

SurveySurvey

Impact (A7) Progress toward commitments Program records (A8) Number of commitments (funding, sponsorship, participation)

Program records

Education Outputs (E1) Number of education related events

Program records

Outcomes (E2) Knowledge of the benefits of handwashing with soap(E3) Knowledge the critical times for handwashing(E4) Soap use during a handwashing demonstration (also a proxy indicator of Behavior Change)

SurveySurveyRapid observation

Impact (B2-6) Behavior change as measured by indicators listed below

(see below)

Behavior Change

Outputs (B1) Number of behavior change communication events(B2) Number of participants at behavior change communication events

Program recordsProgram records

Outcomes (Proxy indicators)(B3) Soap and water present together at a handwashing place(B4) Soap present in the household(B5) Hand cleanliness score (visual inspection of hand cleanliness) (Self-reported behavior)(B6) Self-reported handwashing with soap at any critical event/at specific critical event (Direct observation of behavior)(B7) Observed handwashing with soap and water at any critical event/at a specific critical event

Rapid observationRapid observation3-pt. hand inspection Self-report Structured observation

Impact Prevalence of illness during the 72 hours preceding interview (e.g. diarrhea, or respiratory illness) Morbidity survey

Indicators

GOALPROGRAMCOMPONENT INDICATORS

DATA COLLECTION METHOD

Behavior Change

Outcomes (Proxy indicators)Soap and water present together at a handwashing placeSoap present in the household (Self-reported behavior)Self-reported handwashing with soap at any critical event/at specific critical event (Direct observation of behavior)Observed handwashing with soap and water at any critical event/at a specific critical event

Rapid observationRapid observation

Self-report (questionnaire) Structured observation

Used in MICS/DHS

Limitations and Strengths Indicator Limitations Strengths(Proxy indicators)Soap and water present together at a handwashing place

Soap present in the household

(Self-reported behavior)Self-reported handwashing with soap at any critical event/at specific critical event (Direct observation of behavior)Observed handwashing with soap and water at any critical event/at a specific critical event

• As a proxy, cannot tell us how often hands are washed, if soap or other materials are used to wash hands, when hands are washed

• Over reports handwashing behavior

• Resource and time intensive• Hard to do at scale• Reactivity

• Relatively quick and simple to collect

• Easily incorporated in surveys

• Validated against direct observation of behavior

• Scalable, used in MICS/DHS

• Relatively quick and simple to collect

• Direct observation • Rich detail regarding

behavior

Is monitoring behavior feasible at scale?

• Using proxy indicators at scale is feasible– MICS and DHS indicators will give us key insights

to behavior at the global and regional levels

• Structured observations are difficult to scale, however….– Using representative sub-sets of the target

population to supplement proxy indicators– Using a partnership approach can provide support

for larger scale (Nepal case study)

• National handwashing promotion program – Supported by Nepal’s Private-Public Partnership for Handwashing– Government-lead implementation– Technical, resource and funding support from partners – Capacity building, mass media, door-to-door visits at community level,

school- based promotion

• Clear behavioral objectives – MICS/DHS handwashing indicators needed to be supplemented by

structured observation

• Robust monitoring and evaluation plan (UNICEF, UB)– Structured observation in approximately 1,100 households across

geographical zones

Direct observation of behavior at large scale -Nepal Case Study

Today’s discussion

• Value of monitoring behavior• Examples from implemented programs• Challenges• Ways forward• Gaps we still need to address

Resources

• UNICEF M&E module for programs the promote handwashing

• Practical guidance for measuring handwashing behavior (https://www.wsp.org/sites/wsp.org/files/publications/WSP-Practical-Guidance-Measuring-Handwashing-Behavior-2013-Update.pdf)

• Global Public-Private Partnership for Handwashing (http://www.globalhandwashing.org/handwashing-resources)