Tom Heath, WASH Technical Advisor at Action contre la Faim, is one of the key team members in the WASH’Em project. In this blog post, Tom shares his recent experience in Zimbambwe testing the WASH’Em Rapid Assessment Tools.
I’ve been working in the WASH sector for 9 years across 12 countries. Yet, one thing that hasn’t changed in all this time is the way we do hygiene programs. Whether it is drought response in Ethiopia, conflict response in Iraq, or a cholera outbreak in Zimbabwe, our hygiene interventions tend to look the same. They involve house to house visits where we teach people about disease transmission. If crisis-affected populations are lucky, we leave them with some soap – if they are less lucky, an educational leaflet. Then Global Handwashing Day rolls around and we organize mass handwashing events in schools and all the children get handwashing themed shirts. Interventions like this are well intended but we have no evidence that they actually work to change behaviour.
As a result of a recent collaboration between Action contre la Faim (ACF), The London School of Hygiene and Tropical Medicine (LSHTM), and CAWST (Centre for Affordable Water and Sanitation Technology) I am optimistic that as a sector we can do better. Now I find myself putting that belief to the test. I am standing next to 200 broiler chickens as we record a middle-aged mother wash her hands in the middle of cholera hot-spot zone in Harare.
Zimbabwe officially declared an outbreak of cholera on September 6th and a week later they elevated this to a state of emergency. Zimbabwe has had a sporadic history of cholera, often linked to economic and political instability – but the last outbreak was a decade ago. As of 28th October this year there were 9850 cases and 46 deaths. Cholera Treatment Centres were in place and there was a plan to reach 1.5 million Zimbabweans with the cholera vaccine. However, to stop an outbreak of this scale we also needed to get people washing their hands with soap. Rather than using the same old hygiene promotion approaches we decided to try something new – the Wash’Em Rapid Assessment Tools. These are a set of five tools which are designed to explore handwashing behavioural determinants and facilitate the design of rapid, evidence-based and context specific programs.
It’s really hard to assess handwashing practice, if you ask, no one will actually admit that they don’t wash their hands. Even if you probe or ask to see the soap, it’s hard to tease out the real practice. So reported behaviour is always much higher than reality. The ‘gold standard’ is to conduct extended observations, but this can still be biased and it is not feasible within the time limitations of emergency program design. Instead the Wash’Em approach includes a Handwashing Demonstration tool.
That’s why I find myself in this lady’s house, videoing her has she lathers her hands with soap and rinses them in the handwashing facility near the toilet. We had asked her to demonstrate how she usually washes her hands after going to the toilet. We don’t expect her to show us ‘normal’ behaviour, instead we assume that she will show us her ideal version of handwashing. Later our team sit around a table in the office and play the video recording back. We are looking for barriers in the physical environment that may prevent her from regularly being able to wash her hands. We notice that her daughter had to bring the soap from inside the house – that doesn’t seem very convenient. We notice that the liquid soap used for handwashing is actually designed for dishwashing – we wonder how often it is used for the former purpose. We also notice that the handwashing basin is actually more of a laundry basin. Does handwashing still happen when neighbours have the sink full of their dirty clothes? We do these handwashing demonstrations with 11 households; some households who had been personally affected by cholera and some who had not. Eleven might seem like a small sample size, certainly smaller than a typical needs assessment survey. But these are qualitative tools and our team were surprised that we had definitely reached saturation point with just these few households – there were clear patterns in the types of infrastructure available, where the soap was kept and how hands were washed. Overall the method itself was easy to do, extremely quick, and much more fun than a standard survey. Analyzing the recordings takes a little while to get the hang of – it requires you to think beyond what you first see. This is why the videos are really helpful. It allowed us to watch the handwashing process repeatedly, as many times as was necessary.
A few compounds away from the chickens, some of the other members of our team are in a household where the husband is recovering from cholera. They are going through the Personal History tool with him. The structured and participatory nature of this tool seems to cut through the guff, clearing the way for honest exchanges. We learn about the man’s hopes and dreams, his social life, how others view him, and how getting cholera has affected his hygiene practices. He explains to us that getting cholera had caused him to revalue many things in life. It made him reprioritize spending time with his family and as such he is cutting back on nights out playing snooker with his mates!
I find myself realizing that in all my years of experience I have never really taken time to learn about the people behind the outbreak. As a sector we rarely put a face to the statistics that we often focus on. By doing this activity with multiple people we became more aware of the sensitivities of program design in an emergency like this. We tried to think of ways that we could bring out the voices and perspectives of cholera cases during our intervention.
We get back to the car and catch up with the members of our team who were conducting the focus group discussions. I ask them about one of methods they tried with their participants – the Motives tool. “It was out of this world!” they exclaim! As part of this activity participants are introduced to character cards, each with different personalities. The group then rank the characters in order, from the person who is most likely to wash their hands to the person who is least likely. Is it the person who is a good parent, the person who is well educated, or the person who values looking nice? The tool plays with stereotypes and you get a lively discussion. The male focus group was particularly dynamic and ended up sharing stories about similar people in their community in order to explain the order they had chosen. Why does all this matter? This tool helps you identify the goal-oriented motives driving handwashing behaviour. Knowing this can help you tell stories which will inspire the population you are working with to wash their hands.
In the focus group discussions we also tried the two other tools – Risk Perceptions and Touchpoints. In the Risk Perception activity participants are asked to use a coloured scale to describe their perceived vulnerability and susceptibility to cholera. The team explain to me that the two focus groups responded very differently to this activity. In the first group people were worried about other health issues like TB and cancer. Several participants explained that in their view cholera is a spiritual matter, a curse that can only be prevented through prayer. In sharp contrast, another group included two people who had experienced cholera within their households and they were very afraid.
The last tool, Touchpoints, is very intervention focused and helps you to identify the delivery channels that will be best placed to reach your population. We learned that in this urban area almost everyone watches TV and listens to radio, and most households have one person with a smartphone. Newspapers, on the other hand, were only for the rich, We also learned that in urban areas like this, community meetings didn’t happen in a centralized formal space. Before using this tool, we had had an idea to do outreach at bus stops. Fortunately, this is one of the delivery channels assessed by the Touchpoints tool, which corroborated our idea. It seems that no matter who you are -man, woman or child- you make your way through a bus stop most days. This, we decided, was going to be the focus of our intervention.
An effective emergency response requires managing competing priorities. When I had first arrived in Harare I immediately felt that familiar pressure of needing to act – feeling like I was there to save lives and that there could be no delay. With many other tasks calling out to me it was tempting to push the Wash’Em tools aside and just go with our normal programming approach. But having seen so many hygiene programs done badly I knew that actually we may not be running out there to save lives – we may be running out there to no effect at all. It took me half a day to train my team on the Wash’Em tools and just one day to collect the data with a team of six – in my mind that is an acceptable and effective use of time in any response.
I loved using the Wash’Em rapid assessment tools. Our team worked together to translate the findings into an intervention with some support from the London School of Hygiene and Tropical Medicine. We returned with our data on Thursday and by Monday we had a full outline of what we were going to do. We are now incorporating these ideas into our existing program.
About this project
“This project is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Action contre la Faim (ACF), The London School of Hygiene and Tropical Medicine (LSHTM), and CAWST (Centre for Affordable Water and Sanitation Technology) and do not necessarily reflect the views of USAID or the United States Government.“