Using Wash’Em to Design Handwashing Programmes for Crisis-Affected Populations in Zimbabwe: A Process Evaluation
Abstract
:1. Introduction
1.1. Hygiene Programming in Crises
1.2. The Wash’Em Process
2. Materials and Methods
2.1. Study Site and Population Demographics
2.2. Study Design and Framework
2.3. Data Collection
2.4. Interviews with Wash’Em Implementers
2.5. Observation, Notetaking, and Photography
2.6. FGDs with Crisis-Affected Populations
2.7. Secondary Analysis of Programme Documents
2.8. Data Management and Analysis
3. Results
3.1. Description of Study Participants
3.2. Category 1a: Implementation of the Wash’Em Process for Programme Design Compared to the Intended Process
Fidelity and Coverage
3.3. Category 1b: Implementation of the Wash’Em Designed Programme Compared to the Intended Process
3.3.1. Fidelity
3.3.2. Coverage, Dose Delivered and Received
3.4. Category 2a: Receipt and Mechanisms of Change (Implementers)
3.4.1. Feasibility (Process)
3.4.2. Feasibility (Programme)
3.5. Category 2b: Receipt and Change Mechanisms (Crisis-Affected Population)
3.5.1. Acceptability and Relevance
3.5.2. Participant Engagement and Response
3.5.3. Mediators
3.6. Category 3: Context
4. Discussion
4.1. Implication of the Findings for Improving the Wash’Em Process
4.2. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Rapid Assessment Tool | Description | Modality and Suggested Sample Size | Further Resources |
---|---|---|---|
Handwashing Demonstration | Designed to generate quick insights into whether a person’s home and community environment enable or prevent handwashing practices. Participants are asked to demonstrate how they would normally wash their hands and data collectors’ video this process and then answer a series of questions about how participants interact with objects (for example, soap and containers) and infrastructure (for example, handwashing facilities and water points) and whether there are factors in the physical environment that may enable or create barriers to handwashing. | Individual method done at the household with a minimum of 10 people. | Full Rapid Assessment Guide available in Supplementary Material Document S1 |
Motives | Designed to identify what is driving handwashing behaviour or preventing it in a particular context and which motives shape people’s identity and other behaviours. Participants are introduced to a set of character cards that are linked to behavioural motives (e.g., an image of ‘A person who has lots of friends’ is used to epitomise the affiliate motive and the desire to belong to a social group). Participants are then asked to rank the character cards based on which character they think is most likely to always wash their hands with soap to the person who they think is least likely to practice handwashing with soap. | At least 2 focus group discussions with different sub-groups of the population. | Full Rapid Assessment Guide available in Supplementary Material Document S2 |
Disease Perception | Designed to understand people’s perceptions of the disease of interest (e.g., diarrhoea or cholera). The group is asked to identify 5 illnesses they are most worried about, the illnesses are then ranked in order of which ones they worry most about to which ones they worry least about. Participants are asked to grade their perceptions about the disease on Likert-style scales. | At least 2 focus group discussions with different sub-groups of the population. | Full Rapid Assessment Guide available in Supplementary Material Document S3 |
Personal Histories | Designed to obtain a broad understanding about the experiences of populations affected by crises or outbreaks. Participants are asked to talk about three different time periods (before, during, and after the crisis). Participants will draw an image that reflects how they looked and felt at each stage, to help participants open up and share their experiences with the implementers. | Individual method done at the household with a minimum of 6 people. | Full Rapid Assessment Guide available in Supplementary Material Document S4 |
Touchpoints | Designed to identify the types of delivery channels that are present in a context and prioritise which ones are likely to be most effective in reaching your population. Participants are presented with image cards depicting different touchpoints (e.g., radio, village meetings). Participants are then asked if each touchpoint reaches a lot of people in their community and identify sub-groups such as ‘women’ that this touchpoint is particularly effective in reaching. | At least 2 focus group discussions with different sub-groups of the population. | Full Rapid Assessment Guide available in Supplementary Material Document S5 |
Category | Domain | Definition |
---|---|---|
1a. Implementation of the Wash’Em Process | Fidelity | The content and quality of the implemented Wash’Em design process compared with what was intended. |
Coverage | The degree to which staff participated in each stage of the Wash’Em process. | |
1b. Implementation of the Wash’Em Designed Programme | Fidelity | The content and quality of the implemented activities compared with the Wash’Em guidance for those activities. |
Coverage | The degree to which the crisis-affected population were exposed to the intervention. | |
Dose delivered and received | The number of activities that were intended to occur as part of the Wash’Em implementation compared to what actually happened. | |
2a. Receipt and change mechanisms of the Wash’Em programme design process | Feasibility (Process) | The extent to which implementers feel they can follow the steps of Wash’Em and implement the Wash’Em designed activities in a crisis. Assessing this will take time, cost, logistics, and capacity into consideration. |
Feasibility (Programme) | The perceived feasibility of implementing Wash’Em designed activities according to implementing staff. | |
2b. Receipt and change mechanisms of the Wash’Em Designed Programme | Acceptability and Relevance | The extent to which crisis-affected populations feel the programme activities are acceptable, appropriate, and relevant to their needs and situation. |
Participant engagement and response | Receipt and understanding of key messages, and interaction with the programme content. | |
Mediators | Specific behavioural determinants measured along the hypothesised causal pathway. | |
3. Context | Context | Anything external to the Wash’Em process that may have acted as a barrier or facilitator to its use for programme design, implementation, or its effects. |
Research Method or Data Source | Respondents | Purpose | Process Domains Covered | Programme Domains Covered | Sample Size |
---|---|---|---|---|---|
Interviews with Wash’Em implementers | Wash’Em Implementers | To understand the expectations of implementing staff in relation to the feasibility and usefulness of the Wash’Em process and its likely outcomes. | Fidelity Context Feasibility | Fidelity Context Acceptability | 11 implementing staff |
Observation, note taking and photography | Wash’Em implementers and to a lesser extent the crisis-affected populations that they are interacting with | To understand whether the Wash’Em implementation was implemented as intended and record whether any events deviate from the intended process. | Fidelity Context Coverage | Fidelity Context | 12 implementing staff Observation to take place within the office and within implementation sites |
Focus Group Discussions | Crisis-affected populations who are exposed to the intervention | To explore reactions to the Wash’Em activities and generate reflections on what was liked or disliked about them. | Acceptability Participant engagement and responses Context Relevance | 9 focus group discussions | |
Secondary analysis of programmatic data | Wash’Em implementers | To gather data on planning, programme targeting, training, budgeting and programmatic adaptation. | Fidelity Context Feasibility Coverage | Dose delivered Fidelity Coverage Context | As available |
Category | Domain | Quote | Quote Number |
---|---|---|---|
1a. Implementation of the Wash’Em Process | Fidelity | ‘The disease perception tool wasn’t contextual because in the community where we worked no one was affected by COVID-19, no one was succumbed to any diarrhoeal disease. No one lost his or her relative. With regards to COVID-19, so we didn’t find it fit to conduct it but we did train the facilitators on the tool in case we have such a situation as a disease outbreak. We just used the three tools; handwashing demonstrations, motive mapping and touchpoints as they were the most relevant to the community.’ (Implementer, female). | 1 |
1b. Implementation of the Wash’Em Designed Programme | Fidelity | About the commitment card activity: ‘Village Health Workers actually walked door-to-door and they explained to us what we were supposed to do. We wrote what we wanted to do and these were put on the doors or cupboards, we actually wrote timelines.’ (Community member, Female). | 2 |
Dose delivered and received | ‘However, the challenge we faced when they came was that they conducted the door-to-door visit without informing us that they were coming so we had to come back from the farms to attend to them. Thus, there was lack of communication.’ (Community member, Male). | 3 | |
2a. Receipt and change mechanisms of the of the Wash’Em programme design process | Feasibility (Process) | ‘I think, in terms of programming, I realised that most organisations usually they rely much on top–down approaches where interventions are not informed by community views and community perceptions with regard to their needs in hygiene promotion. So organisations just show up and they say this is the programme we have for you. And the community does not have any opportunity to share their views… The issue of collecting baseline data to inform programming, like we did using the Rapid Assessment Tools, it is a very good idea because it promotes informed programming by virtue of the communities also being involved in decision making on what needs to be done in their communities. I’ve seen that work very well.’ (Implementer, Male). | 4 |
Feasibility (Programme) | ‘I’d say budgetary constraints, Wash’Em we are running on a shoestring budget. So that is a challenge.’ (Implementer, Female). | 5 | |
2b. Receipt and change mechanisms of the Wash’Em Designed Programme | Acceptability and Relevance | ‘It [Being pulled in different directions] also zeroed in on the patriarchal nature of our society, were the women carry on the burden of the house chores. You know, and the men were like “aaah” [realised] our women are overwhelmed. So yeah, that was one of the impacts. Of course, the women who themselves are more hands on the day-to-day house chores appreciated that it was important to wash hands at every critical point, but the men were also in agreement that the women are overwhelmed.’ (Community member, Male). | 6 |
‘This [The dye on Food activity] was relevant because since this activity was done in our community it seems that children are not getting sick anymore. Children got sick very frequently in the past, before they came with this activity so it is likely that the mothers would feed their children without washing their hands.’ (Community member, Male). | 7 | ||
Participant engagement and response | ‘I think this activity will influence our behaviour more this time because of the cholera outbreak everyone seems to be alert in terms of good hygiene practices. If we think about the amount of time spent doing different chores it shows that we have to pay serious attention in washing hands thus it will not affect us’. (Community member, Female). | 8 | |
Mediators | ‘This is something that we cannot forget because this activity was done last year, we still remember this information, and we are actually practicing it even if we are busy with other things.’ (Community member, Male). | 9 | |
3. Context | Context | ‘Some of us, we have a challenge of water so if I use more water, then it means I should spend more time in fetching water to practice what we learnt. So for me I feel like AA could have given us a close source of water for us to practice this because we women suffer more in terms of fetching water.’ (Community member, Female). | 10 |
Activity | District 1 | District 2 | ||
---|---|---|---|---|
Activity Recommended? | No. Events Activity Was Implemented in | Activity Recommended? | No. Events Activity Was Implemented in | |
Being pulled in all directions: A participatory play about a hardworking mother designed to link handwashing to being a good parent. | ✓ | 6 | X | 4 |
The power of soap: An interactive activity were people rub glitter on their hands and the try to remove it with water only, before successfully removing the glitter with soap. Designed to demonstrate that soap should always be used for handwashing. | ✓ | 6 | ✓ | 0 |
Pledging: Community members and community leaders make public pledges to make handwashing a priority. Designed to make handwashing appear to be a normative and socially approved behaviour. | ✓ | 6 | X | 4 |
Commitment card: A household-level planning tool to encourage people to take small doable actions towards improving handwashing behaviour. Designed to improve the sense of ownership around handwashing facilities. | ✓ | 6 | X | 4 |
Dye on food: Using food dye, this activity is designed to demonstrate how germs can easily spread from hands to food. | ✓ | 6 | X | 4 |
Child life game: A participatory play at a community event to show how the lives of two children can be dramatically changed by small moments of their lives, including the frequent practice of handwashing with soap. | ✓ | 0 | X | 4 |
Social media tips: By creating a social media page or group where you can obtain tips from community members who have improved their handwashing facilities. Designed to help make handwashing seem normative. | X | 0 | ✓ | 0 |
Testimonies from survivors: Document stories of disease survivors and their experiences of contracting a disease and then share this with other people in the community via video or radio. Designed to help population appreciate the full range of consequences if a family member gets sick. | X | 0 | ✓ | 0 |
Can you smell the truth? Use a blindfold test to demonstrate how hands washed with soap smell good, while hands ‘washed’ without using soap do not. Designed to make participants realise that soap is key, and handwashing with water only is not effective. | X | 0 | ✓ | 0 |
Don’t miss out on the experience: This activity involves creating a sign or mural in your community which highlights how great people feel after handwashing with soap. Designed to increase the association between handwashing and feeling comfortable. | X | 0 | ✓ | 0 |
Watching eyes: Create stickers with a picture of eyes on them and place the stickers above handwashing facilities. Designed to make people feel like others are noticing whether they wash their hands with soap. | X | 0 | ✓ | 0 |
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Thorseth, A.H.; Lamb, J.; Mavodza, C.V.; Tembo, M.; Mushangari, A.P.; Zinyandu, E.; Heath, T.; White, S. Using Wash’Em to Design Handwashing Programmes for Crisis-Affected Populations in Zimbabwe: A Process Evaluation. Int. J. Environ. Res. Public Health 2024, 21, 260. https://doi.org/10.3390/ijerph21030260
Thorseth AH, Lamb J, Mavodza CV, Tembo M, Mushangari AP, Zinyandu E, Heath T, White S. Using Wash’Em to Design Handwashing Programmes for Crisis-Affected Populations in Zimbabwe: A Process Evaluation. International Journal of Environmental Research and Public Health. 2024; 21(3):260. https://doi.org/10.3390/ijerph21030260
Chicago/Turabian StyleThorseth, Astrid Hasund, Jennifer Lamb, Constancia Vimbayi Mavodza, Mandikudza Tembo, Anesu Petra Mushangari, Eddington Zinyandu, Thomas Heath, and Sian White. 2024. "Using Wash’Em to Design Handwashing Programmes for Crisis-Affected Populations in Zimbabwe: A Process Evaluation" International Journal of Environmental Research and Public Health 21, no. 3: 260. https://doi.org/10.3390/ijerph21030260