How does the Wash’Em approach compare with programs you have designed in the past? If you have never designed a program, how do you see Wash’Em contributing to hygiene programming?
Wash'Em vs Other Approaches to Hygiene Program Design
Wash'Em vs Other Approaches to Hygiene Program Design
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The WASH'Em approach is completely different from the way we used to design our hygiene programs in the past. We used to design based on general perceptions and information collected from the field regardless of it's relevance to that specific context. but the WASH'Em approach is designed in a way that the hygiene programs are evidence based and contextualized at the same time.
One good example is that we used to write in our programs that 15% percent of the target population properly wash their hands in most of WASH programs in country X for about 10 years but this was not actually representative to the reality on the ground because country X had different regions with different contexts and thus we could demonstrate the facts in each region rather than generalizing the situation at national level. Although some times there can be an average national statistics of handwashing practice but we were targeting specific regions of country X.
Having supported a variety of approaches and programs over the last years, I am particularly impressed by the amount of formative research that goes into WASH'em, especially in an emergency context, where the pretext of "lack of time" is often used to revert back to using the good old IEC materials that we have always used... Taking those couple of days to really understand the targeted populations barriers, attitudes, reasons for practicing or not hand washing, will pay off in the long run through actual impact of the activities implemented vs. a "business as usual" approach that might not resonate at all with the population we are trying to serve. Going forward I would love to hear from other participants and the methodologies they have used successfully, which include formative research in any form, shape or way and if anyone would have any RANAS experience to contribute I would be specifically interested to see how both models compare in terms of work load, ease of use, context adaptability etc.
I have heard of formative research while designing behaviour change programme but not fully engaged in the process. I would like to be part of this research from which I can get hands on knowledge for effectively designing the behaviour change programme.
I particularly appreciate the emphasis on physical handwashing stations, both in program design (noting hygiene promotion can be ineffective if people do not have access to soap and water) or in program evaluation (using the global handwashing indicator rather than asking about key handwashing times). In the past, I have definitely been guilty of running programs that both focused on hygiene promotion only and evaluated program success via knowledge of key handwashing times. I look forward to designing and influencing more evidence-based, impactful programs in the future.
I definitely agree with this. We can promote behaviour when we provide communities with basic hygiene items such as soap and water. If they lack these items, it is hardly possible to change their behaviour. We need to add to our project budgets.
Hey, while I agree - it is impossible to wash your hands if you don't have water and soap - adding too much hardware components into a HWWS project often ends up leading the focus away from the behavior change components and we "run" to get the hand washing stations done and the project is considered over. So yes we should use a hardware related indicator, but not without one aiming at measuring behavior change (proxy if self reported doesn't work) as well in my opinion. UNICEF actually has quite a nice collection of indicators (full M&E guidance actually) that work for the development context but can be adapted and used in humanitarian settings as well. You can find them here: https://www.unicef.org/documents/handwashing-promotion-monitoring-and-evaluation-module
Interesting. Evidence shows that the programme should encompass both hardware and software. Most of the handwashing stations are not human-centered design. I felt that most of the time it's assumed that people need a handwashing stations while sometimes there is no water, no solution for soap. So it's like telling people to eat salad but they have no access to it. However, I was not sure how WASH'EM can help with the hardware human centered-design. If anyone knows how, I am happy to learn more.
Agree, Fabienne - it would be interesting to see whether the application of WASH'EM, as a tool to promote inclusive design of behaviour change programming, can also improve the extent to which inclusive designs on the hardware can be realised in a manner that is less of a tick-box approach (merely engaging the community on the location).
I agree with you Deborah, I also like the emphasis on physical handwashing stations. As you said some hygiene promotion programs just focus on the knowledge, because handwashing facilities are seen as hardware and that is a task for the hardware team and not the hygiene promoters. I also find really interesting what Fabienne and Xander said about handwashing facilities design. I am also curious to see if and how Wash’Em could help more inclusive designs of the handwashing facilities.
A lot of great comments, which I second almost in full. I also believe that an handwashing program should aim at promotion behaviour change while supporting with adequate infrastructures. What I like of the focus on hand washing stations and solutions like adding "mirrors" or "nudges" is the aim of making sanitation infrastructures (which in many emergency contexts are common and shared) nicer. This is also a strong motivation for people often forced in poor living conditions, where shared services are poorly maintained (dusty, rusty...). In Cox's we have some examples of WASH infrastructures that communities not only use but also like, because they have bright colours, shade, and some nice adds-on such as soap holders, hangers for bags, mirrors indeed... And this is clearly helping the "next step" which is the O&M and the sustainability.
As part of the COVID-19 response and also previous to that for EVD preparedness in S Sudan, we installed many handwashing facilities in health centres. I was surprised to see most with used soap bars (rather than unused) and filled with water - some evidence of being used, although I rarely actually saw them being used.
My feeling is with many centrally funded large programmes, handwashing facilities are an easy box to tick but the hygiene promotion behind a successful handwashing programme is more difficult. These also meet the JMP indicator; actually getting sustainable changes in behaviour as the SuperAmma campaign is more difficult to measure.
With Wash'Em it would be interesting to see in more detail what the assess and build and create stages really are - how to get an awareness of culture and motivations behind behaviour change for instance in a rapid but effectual way.
Handwashing stations appropriately located and with soap and water present are both the signs of use (thus monitoring indicator, a good one though proxy) and nudge to washing hands. This had been made use of rightly as the Global Hand washing indicator in JMP Hygiene | JMP (washdata.org). On the other hand, lack of handwashing station with soap and water always present at the convenient place is the largest barrier to washing hands. In Bangladesh and Nepal where there are hand operated tube wells, people are found to be washing their hands at the tube wells itself, making it very difficult particularly for those who cook and look after the children to wash hands before cooking, before feeding the child and after cleaning child’s bottom particularly during night.
Wash'em is quite a commendable approach that is very context-specific in collecting perceptions with regards to handwashing behavior change. However, l strongly believe that it needs to be well resourced in order to be properly implemented. Programs should include in their budgets all the resources needed for the exercise to take place smoothly, i.e human resources, the training kits, the cameras etc.
agree
This is very relevant to a current program I inherited when I joined the organization where I'm currently working. As a response to COVID-19, our team's intervention was to install handwashing stations in public places. The technical design of the station was sturdy and the structure was superior to many other advanced designs, yet these elegant handwashing stations are not used at all for the purpose they were designed for. The intervention lacked insight into the user's needs and motives and completely disregarded the human considerations. PDM revealed that the sturdy design served a complete other purpose. I can easily say that this campaign was a failure.
I see however, that WASH'em approach can help in designing programs that are based on evidence but also structured around user's needs. That should ensure more tailored interventions with long impact.
I'm so curious: what purpose were the handwashing stations used for instead?
After our fist quick PDM, we found that they were used for drinking, for team making (a common practice), for 1 that was installed in the hospital it was used to clean guts of slaughtered animals in a slaughterhouse nearby! otherwise, they were simply not used. We will do an indepth PDM to try and understand the needs and these deviating practices and try to adapt these stations accordingly.
In my view the consultations (interviews and focus groups) done with community to assess the existing context and causes and then providing informed solutions which are guided by people existing behaviours sometimes linked to the personal histories are critical and key for Wash'Em
WASH'Em is relatively close to what we used to do. In regards to handwashing, previously we used to design handwashing facilities for each latrine we construct, but we found out they are never used. Somalis, WASH their hands inside the latrine because they use water, therefore, we have added ebrik (2-litre water container) as a part of the hygiene kit. Later in our responses, we provided hands-free handwashing facilities near health facilities.
WASH'Em provides a step-wise guide for hygiene promotion interventions including assessment, contextualization, motives and implementation. This is a very useful tool, and it will help us guide more. Furthermore, making handwashing from locally available material is a good approach.
Thanks for sharing Zakaria! I've been in the same situation regarding not-used handwashing stations, and I believe is a great lesson learned on how important is to properly assess the context and consult with the communities before designing our programming.
In emergency settings, we used to design hygiene promotion programs based on information sharing and very little analysis of the barriers and enablers for efficient behavior change - something that I'm trying to move away from! Currently, more community engagement and understanding of the context and the particular situation of the communities are in place, still, teams struggle to conduct a proper analysis and design an impactful handwashing program that is not only based on "sessions". I'm very excited to see how organized and structured WASH'Em is and how having such a clear methodology could support us in improving how we approach handwashing promotion.
Especially in the emergency context, it's easy to see how we design programs based on perceived need without properly going through the steps to drive behavioral change. I agree, it's nice to have the WashEm tool to create an organized, structured method for improving handwashing.
I would like to get more information about the approach. Up to now, the cycle and processes seem pretty close to what I have worked on within my last missions. I like that the approach is created after long and in-depth research and that it seems "easy" to apply, but especially that it can become a tool that might be used as a roadmap for implementation.
From my experience in the field, specifically implementing HP programs, the lack of knowledge makes us doubt the activities for each phase of the cycle, especially those that are people-centered. When reading the document from the introduction module, I was pleased to see examples of community engagement activities that are sometimes difficult to find and put in place.
For decades we have tried to encourage people to wash their hands in so many ways with so little success; I hope Wash'em brings us new perspectives. I'm curious about time constraints in emergencies and advice or guidance on what to do in terms of action on the first days of the emergency when doing the first assessments. How to take advantage of those first 48 hours action-wise...
I agree with your sentiments, Maria. Between the lack of knowledge applied to HP programs, and indeed, we have been trying to encourage handwashing for decades with low success rates…and the fact that we are still seeing plenty of ineffective HP programming with the old “Wash your hands! Wash your hands!” megaphone tactics – I remain excited and hopeful for what Wash’Em has to offer!
I am also curious as well. I was browsing some case studies who used the tool and their findings. I am curious at which stage the tool is used during the emergency ? Maybe not during the first 72 hours and later. I didn't find the answer. I am seeing the approaches as making sure the intervention is more human centered designed than just offering a service based on assumptions. For instance, community engagement requires some sort of social cohesion. I am not sure during the first few days of an emergency, we have social cohesion. Maybe the tool is better to be used later when designing the programme. Let me know your thoughts about it.
To be honest, I am new to Wash'EM approach of of hygiene programming. To date, I have never seen any approach focusing only on hand washing. I and my colleagues used a mixed behavior change approach, not differentiating the emergency and development context. After being introduced to the Wash'EM approach of program design, I will be using different approach for emergency context differentiating it from the development context, and following the different step by step approach focusing only on hand washing.
It's the same for me, I had never known or developed any tools specifically related to hand washing. But this training allowed me to understand that by using this approach and the associated tools, it is very relevant for the implementation of the project, and even beyond handwashing I think.
I have same thoughts as we used to design the WASH interventions based on a mixed of communication approach and not based on contextual analysis and evidences. I'd be keen on learning about how to apply similar approach to design evidence-based hygiene program in development context, not emergency only as this is very practical and relevant.
I am highly interested to apply the Wash'EM approach of hygiene programming in my organization's WASH intervention on the ongoing emergency responses. The context is that we have been responding to different types of emergency such as conflict, flood, drought and outbreaks. My point here is to know in which of the emergency response context that Wash"EM is best fitting? or is it can be applied to any emergency response set up: IDPs, Refugees, host communities....? Second, there are different actors ( implementing partners) in a single refugee camp or IDP collective centers. So, how these different actors can be organized/coordinated to apply this Wash 'EM programming? For which of the emergency type this Wash"EM approach best used for effective outcome, rapid onset emergency of protracted one?
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Desalegn, Wash'Em works well for all of the main crisis contexts. It was designed with disasters, displacements and outbreaks in mind.
One thing i find very interesting is the fact that the WASH'Em method focuses on the Motivators but not the Barriers the same way. The Motivators tool is straight forward and easy to understand. There is a tool that askes about what motivates people to change their behavior. However, Barriers to behavior change are sort of woven into the handwashing tool as well as the personals history tool in combination with the risk perception. I wonder why there is not a tool that is outright asking for possible berries to washing hands the same way there is a tool for motivators?
To my mind having berries next to the perceived practices (handwashing tool) Motivators and risk perception would make more sense than the personal history tool. As it is more streamlined towards behavior then asking about life in general. Maybe I am missing something important that I have not understood
Hi @Florian Haas This is an intersting point, you are right that the tools don't tackle barriers through a dedicated tool but try to weave learning about barriers thoughout each tool. I would be particularly intersted to learn from you about what types of behavioural barriers you think are not currently piced up by the tools. We are open to modifying things if you think the inclusion of certain additional questions might generate data which would be useful for improving programming.
For some background context the tools were refefined from a set of about 15 initial tools that we piloted in several countries. These broader set of 15 tools aimed to explore invidividually each domain of behavioural determinants that were documented in the literature. We refined them to make them as easy as possible to do and prioritised those which we felt could generate information which would lead to concrete programmatic decision making (e.g. routines are an important determinant of behaviour but it was hard to use data about routines to shape programming). This also meant that we depriortised methods which seemed to generate similar information across contexts (e.g. the way that people prioritise water and soap is an important determinant but is actually remarkably similar across contexts). In some cases we also combined methods which is why the disease perception tool now covers information related to risk, norms, and broader health concerns. We did experiment with some approaches where people were asked directly to list barriers to handwashing. However responses are quite similar to this question. People typically focus on factors that they feel are partially or fully out of their control e.g. sufficient access to handashing facilities, water and soap. Some also cite cognitive factors such as being busy or forgetting to handwashing at critical times. We have tried to factor in these concerns throughout Wash'Em recommendations since they are shared across contexts.
Dear Sian, thank you for your answer. There is clearly a lot of thought and social science that went into the WASH'em tools. To me it was just interesting that motivators are its own tool and quite straight forward. Barriers however are woven into the other tools. Giving it a bit more thought on my part, i guess people are more willing to talk about what motivates them. Barriers are not always as clear cut. So it makes sense that way.
I am sorry about not being very clear with my thoughts. In my experience on being in the acute phase of emergencies over the last years i am not sure i would have felt comfortable using the personal history form as i have the fear i would retraumatize people who eg. just fled from war. In this instances I was wondering if there is an alternative tool to use. So my question is more based on the research that you have done is there a tool that sort of gives a similar insight into the reality of people while not having them relive what they went through?
As my WASH background has all been development programming up until now (i.e. I only just started working in humanitarian response), the majority of my experience with hygiene program design has involved long-term planning and execution (w/ assessment/analysis) – which is very different from the Wash’Em approach. I see Wash’Em as a tremendous contribution to hygiene programming, especially given its ‘ease of use’ and ‘rapid results’, with concrete recommendations. My colleagues at Catholic Relief Services have been training WASH staff in our country program offices for some time now, which has led to quite a few success stories with Wash’Em already and I look forward to helping build Wash’Em capacity near and far!
I have been working in Rohingya refugee response program last 3.5 years in several WASH project (specially targeting Hygiene promotion and community engagement).We have implemented one systematic approach for behavior change targeting (Hand washing with soap b) which was going quite well but it took a longer period of time due to COVID and the quantitative survey was sometimes time consuming and disgusting for respondents. For emergency situation we always try to figure out something which is really very quick and effective at the same time. After having some ideas of what actually Wash'EM is ,now we can incorporate it while planning the intervention not only for hygiene as well as for infrastructure. And look forward to using the Wash'EM tools and recommendations while targeting Hand washing intervention in this difficult time of COVID.
I'm fairly new to the hygiene programming aspects of WASH and it’s been helpful through this learning course to familiarize myself with the Wash’Em tools. One of the things I’ve appreciated about Wash’Em is the process it gleans the data from the focus groups and funnels the data through the workbooks to create practical, actionable next steps. Particularly in an emergency context when you are unlikely to have the time to do extensive baseline assessments, Wash’Em seems to provide a fairly robust approach for timely, practical impact.
When thinking about what I have used before I can see some similitude and differences:
Most approaches I used before required financial resources, time and many participants.
What I like the most so far about Wash'em, is that it provides the tools to explore the determinants of behaviour that tend to vary most in a crisis in a fast way. By being able to perform this analysis rapidly and the guidance provided by the tools, the implementation can begin very quickly, and we can support the communities affected in a more effective way. Other behaviour change approaches, as they are not designed for crisis, are more time consuming, and time is truly relevant in a changing context such as an emergency is.
In my experience of implementing emergency WASH programs, there is a disproportionate reliance on KAP surveys. This is of course not superfluous, and definitely help with the impact monitoring, though challenges include that the MEAL and program teams' schedules are not aligned with the cycle of the emergency (0-2 months), and the fact that the tool and data collection takes place by MEAL limits the extent that program teams take 'ownership' of the process, its outcomes and feedback loops. This training made me realise how WASH'EM can improve the quality and effectiveness of hygiene promotion in emergencies, by giving agencies the tools to further a participatory, culturally appropriate, and evidence-based approach.
Previous experience responding to emergency situations, handwashing was incorporated in WASH programs as part of Infection prevention and control and hygiene promoters were used to sensitize recipients of humanitarian assistance to adopt handwashing with soap as a practice. This followed a supply-driven initiative where for example under camp conditions, communal facilities had handwashing stations filled with water, sometimes with a mixture of jliquid soap. The same approach was applied at public spaces and offices using a common approach to all the people. The experience is that the behavioral aspects were not captured and eventually the water in some stations was used for anal cleansing or other uses other than handwashing. The other stations were not refilled with water, whilst tippy taps distributed would be converted to other uses such as jerry cans for storing water.WASH 'EM incorporates both the physical environmental barriers as well as the social issues that may stand in the way of adoption of handwashing practice and captures the key motivating factors to taylor an approach to design successful handwashing program that resonates with the needs of the community for a specific context.
In the projects I worked on, it was based either on general observation of the communities (without discussing it with them), or directly on what the people said without really checking whether their practices were those mentioned. This approach allows for a better understanding of local practices so that the project can be designed appropriately.
This is basically the same approach even with my experience. Normally it is a situation of user experience from a different context (More or less copy and paste). This has led to approaches that are not sustainable. for instance, waterborne toilets and taps have been installed in my area of operation without a maintenance program.
I am new to the Wash'EM approach of hygiene programming. To date, I have never seen any approach focusing only on hand washing. This introduction will help in ensuring that the approach is context-related and results are obtained in good time.
Wash'EM may be affected by various context as in our case in Egypt as we have refuges from different countries with different culture while in development program we focus on our own culture.
Wash'Em is very similar to how programmes were designed that I have worked on for the COVID-19 response. Although other behaviours besides handwashing were included (wearing a mask in public places, disinfecting frequently touched surfaces and physical distancing). I think being able to still use the BCD approach, but simplified, helps to design a programme that is evidence-based and context specific in emergency settings. Additionally, infrastructure is important because people need to have a place to wash their hands that has both soap and water and I think it's key that Wash'Em emphasises the need for infrastructure, but together with cues/nudges, and motives. Long term O&M of facilities are always a challenge so would be interesting to hear what the experience has been of facilities after a project is completed in a humanitarian setting and what has been done to encourage ownership/maintenance.
The WASH'em tool does a great job at assessing the programming needs of a population through comprehensive baseline investigation. Both the "hardware" and "software" are evaluated to show gaps and barriers where WASH education and intervention will be most effective. I agree, Lara, that I would like to see how monitoring and evaluation are incorporated into the WASH'em approach.
It is very true and worthy noting that installation of handwashing facilities should be seen as one of the important areas rather than just focusing more on hygiene promotion. People should be able to have access to the facilities when they need to wash their hands rather than having to wait at one handwashing station where there are more people which may even have a negative impact
Wash'Em will enable us continue to do more as it will improve the already built strategies that we have used in the COVID-19 Response, like ensuring that handwashing facilities are given adequate attention so that they compliment well with hygiene promotion thereby influencing behavior change positively
I totally agree with you, taking into consideration huge invested made over construction and installation of handwashing facilities, which end up not being fully utilized by intended persons
Wash'Em will help and create new ways to motivate people why is washing their hands are important.
Hi Rasha, how does the Wash'Em approach differ from what you organization is doing now?