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Wash’Em: resources and tools to design handwashing promotion programmes for COVID-19 response

October 18, 2021

This case study was developed by the COVID-19 Hygiene Hub.

Country and region: Global

Organisation: Wash’Em is a 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). It is funded by USAID’s Bureau for Humanitarian Assistance (BHA).

Point person and Role: Sian White, Research Fellow, at the London School of Hygiene and Tropical Medicine

Organisations/Institutions served by the programme: The Wash’Em approach has been used by 59 organisations in 81 locations. It has been used to help inform the design of 32 COVID-19 programmes.

Unique characteristics of the setting: Wash’Em is designed to be used during humanitarian crises and outbreaks. It can be used to design hygiene programmes in the acute phase of the crisis or to adapt and improve ongoing programmes within protracted crises.

Briefly describe the key components of your COVID-19 response programme.

Wash’Em is a process for rapidly designing evidence-based and context-adapted handwashing promotion programmes in crises and outbreaks. This process involves using 5 rapid assessment tools to understand behaviour. The Rapid Assessment tools are participatory methods which each explore a different determinant of handwashing behaviour and are designed to generate the kinds of data needed to influence program design. The findings from the tools are entered into the Wash’Em software which selects from 80+ handwashing activities to provide a tailored set recommendations for the users context. Each activity comes with a step-by-step guide to aid organisations in planning the logistics and delivery of their programme. The process can be completed in as little as 4 days.

In the early stage of the pandemic, we developed a COVID-19 guide with activity explainers, we ran a series of webinars, developed videos of activities and video blogs about some of the technical aspects of handwashing. These resources focused on low-cost and feasible actions that actors could take to promote handwashing in the early stages of the pandemic.

As we have transitioned from the acute phase of the response into a phase of longer-term programming for COVID-19 control, we have been learning from our users about how they have safely and effectively used the Wash’Em approach to shape their COVID-19 programmes. This has included developing remote training packages, providing direct support to many users and developing materials that summarise safe and effective ways of working during the pandemic.

What process did you use when designing your COVID-19 response programme?

Wash’Em was developed through several years of research and learning. Firstly undertook a review of the literature to understand the determinants of handwashing behaviour. We found that little was known about how hygiene behaviour changed during emergencies and therefore undertook in depth research in crisis affected countries and during outbreaks to understand the factors that influence hygiene behaviour. Lastly we interviewed humanitarians to understand how hygiene programmes are currently designed and the challenges they face.

The Wash’Em process was developed based on this learning. On Global Handwashing Day in 2018 we launched the Rapid Assessment tools and over the course of the following year these were used by 45 organisations in 34 humanitarian crises and were iteratively improved based on user feedback. During 2019 we also released a training package and some supplementary guides. The Wash’Em software was launched on the 10th of March this year.

In the week before the software launch we decided that we would make some last minute changes. At this time there were just over 30,000 COVID-19 cases globally, and while much of the world was not that worried, we anticipated that things may get worse. We adapted the software so that COVID-19 could be selected as an outbreak option and adjusted the algorithms accordingly. However, we also decided to caution against using Wash’Em in its standard face-to face form in areas with confirmed community transmission because of concerns about staff and community safety. Instead we developed the WASH’Em COVID-19 guide which provided a set of 5 activities that were COVID-19 relevant, were likely to work across settings and could be done right away.

In the weeks that followed, our COVID-19 guide was downloaded thousands of times, shared across the sector and many INGOs and NGOs started implementing the activities. We were requested to translate the guide into six languages, run webinars in 4 languages, provide answers to common handwashing questions and provide tailored support to organisations. The huge demand for guidance on hygiene programming during the pandemic led us to set up the COVID-19 Hygiene Hub with LSHTM, CAWST and a network of partners.

As the sector shifted to longer term programming we noticed that the full Wash’Em process was being used by many actors globally. We followed up with these users to learn from their experiences so that we could summarise and share these tips with others. We also developed an online version of our training which was piloted with ENPHO in Nepal and for Tearfund globally. The training used an interactive whiteboard to allow participants interact and role play the tools in a way which mimicked a real life classroom.

What is one thing that has been working really well so far and is there something other programmes could learn from this?

The strength of the Wash’Em project has been that we have always put the needs of our users at the heart of what we do. We certainly did not anticipate launching our software at the beginning of the pandemic, but we were able to adapt our process to suit the current circumstances. This was possible because we have a team that are passionate about this project, who have diverse skills, and who have already spent years understanding the challenges humanitarians face in outbreak situations.

What is one challenge that you have encountered and how are you trying to overcome this?

The pandemic has encouraged a lot of new actors to enter the sector and get involved in hygiene promotion. Many of these new actors first discovered Wash’Em via our COVID-19 guide rather than by trying out the full Wash’Em process. As such, many of these actors are thirsty to get the longer list of Wash’Em activities, rather than using the full Wash’Em process to learn about behaviour in their context and then receive tailored programme recommendations. Sharing the list of Wash’Em activities with those actors was a challenging decision for us.

Ultimately we decided not to release the full list of activities because we felt that it would result in organisations taking short cuts and skipping the Rapid Assessment tools. We feel that the Rapid assessments are the most important part of Wash’Em since they provide a meaningful way of listening to communities and engaging them in the programme design.

How have you been engaging users throughout your programme and what feedback have you received?

Ever since Wash’Em began, we have prioritised learning from humanitarians and shaping our products to suit their needs. During the pandemic we have continued to learn from and provide support to users. The chaos of a pandemic can make people reluctant to try a new approach to programme design. In such cases it helped that potential users could arrange a call to ask questions and receive tailored support. We also actively followed up with all users so that we could learn about what was working or proving challenging. This learning proved incredibly useful and has allowed us to provide more clear guidance about doing Wash’Em safely during the pandemic.

For instance, we learned from GOAL’s experience in Honduras that it is possible to do the Wash’Em focus group discussions (FGDs) remotely using commutation platforms like Facebook Messenger and video calls. They provided mobile data bundles to participants to avoid participants being charged and they buddied older people with their grandchildren to make sure everyone could be engaged via this technology.

We also learned from Oxfam’s work in the Philippines that it was possible to remotely train local staff to implement Wash’Em face-to-face. To minimise risk, they conducted interviews outside and with masks on. They reduced the size of FGDs and just brought neighbouring households together. They asked all participants to wash their hands before and after the discussion and got them to maintain physical distancing throughout.

Oxfam staff in the Philippines facilitate a FGD to learn about handwashing motivations.

How might your experiences responding to COVID-19 change the way your organisation designs and delivers hygiene programming in the long-term?

One thing the pandemic really reminded us about was the importance of working through different languages. We had always had plans to translate our materials into French, Spanish and Arabic but the pandemic demonstrated to us that translation of key resources has to be prioritised, particularly when dealing with a novel pathogen. In the first few months of the pandemic, many countries struggled because of the ‘English infodemic’ around COVID-19. The success of our resources was partially due to an absence of other resources in these languages. This is a lesson we will be taking forward in our Wash’Em work and was something that shaped the way we designed the COVID-19 Hygiene Hub.

Wash’Em has always aspired to reduce the need for international behavioural consultants to fly into crises to aid with programme design. Instead we want all humanitarians to feel that behaviour change is something they are capable of. In many ways, this has made Wash’Em perfect for use during the pandemic. However, it also challenged us to invest more heavily in remote learning modalities. This is something that we plan to continue and expand in our next phase of work.

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