November 6, 2020

By: Lily McCann, FHI 360/Global Handwashing Partnership

On October 1, 2020, the Global Handwashing Partnership launched the Handwashing Thursday Series. The series aims to amplify the launch of the Partnership’s most recent publication: The Handwashing Handbook. The handbook launched on Global Handwashing Day 2020, and it serves as an all-in-one resource for handwashing programming.

The third webinar of the series was held on November 5, 2020 with a focus on monitoring and evaluating (M&E) handwashing programs. This webinar was designed in response to several questions received about monitoring handwashing programs, emphasizing M&E processes as key to optimize the outcomes of a program.

Measuring Handwashing Behavior

Dr. Katie Greenland from the London School of Hygiene and Tropical Medicine began the webinar with a presentation that covered common methods to measure handwashing behavior. She began by explaining that behavioral outcomes can be assessed as primary outcomes (whether a program has changed a behavior), or as secondary outcomes (to understand the mechanism by which an intervention has brought about a health impact).

There are a variety of methods we can use to measure behavior as highlighted in the table below.

Although reported behavior such as self-report can capture large amounts of data fairly quickly, they can be subject to bias. Proxy measures, such as spot checks for the presence of soap and water, can be a useful predictor of poor hand hygiene, but cannot be used as an independent measure of handwashing. Finally, direct measures such as structured observation or videos are beneficial as they are objective measures of behavior, but they are both costly and susceptible to reactivity.

Monitoring Hand Hygiene for All

Next, Mr. Peter van Maanen from the Joint Monitoring Programme (JMP) presented the initial findings of an ongoing mapping of hand hygiene monitoring tools under the Hand Hygiene for All initiative. He began by introducing the Hand Hygiene for All initiative as a call to action for all of society to achieve universal hand hygiene and stopping the spread of COVID-19. The initiative’s Monitoring Working Group is mapping existing monitoring tools and guidance materials. This mapping is important to conduct a gap analysis of tools in different settings. Mr. van Maanen then provided 3 examples of monitoring strategies, many of which assess the availability of infrastructure and consumables, operating and maintenance of the handwashing facility, its accessibility, and sometimes actual practices.

Finally, Mr. van Maanen summarized a synthesis of the available data on hand hygiene published by the JMP. The JMP compiles data from national surveys, which are relatively reliable, relevant, and can be used to compare progress between countries. Information about the JMP and its methodology can be found at https://washdata.org/

Handwashing M&E for Program Improvement in Ghana

Dr. Ben Tidwell, a Senior Technical Advisor for WASH Behavior Change and Research at World Vision (WV), continued the webinar by sharing the experience of the WV Ghana office. In the past, WV monitoring was not done with a regularly conducted, population-based survey, but instead was carried out alongside programmatic activities. As a result, there was no ongoing monitoring afterwards to assess behavior change and sustainability.

To remedy this, WV began piloting the Nurturing Care Group, which allows people to choose a Care Group Volunteer (CGV) to attend a lesson (spot check) twice a month and relay the information to their neighbors.

Dr. Tidwell explained that this technique is not only useful for behavior change promotion, but it has opportunities for strong M&E for handwashing programming including:

• Assessments, such as population-based surveys, can be carried out during regular spot checks.
• Results from these spot checks are recorded to allow for regular monitoring and multiple opportunities for interactive troubleshooting sessions to understand barriers to handwashing faced by program participants.
• CGV reporting back to neighbor groups allows for collection of a “census” every two weeks, allowing for rapid programmatic adaptation where necessary.

WaterAid’s M&E Activities

Finally, Dr. Om Prasad Gautam, a Behavior Change Scientist who works as the Global Lead for Hygiene Behavior Change at WaterAid UK, highlighted how a theory of change can inform M&E activities. Firstly, he emphasized the importance of defining outcomes (behaviors you want to achieve) and impacts (what you want to contribute towards). These indicators are assessed both from outcome evaluations and process monitoring. Through an outcome evaluation, we assess the effect of the intervention in improving behaviors. Baseline and endline evaluations are instrumental to show the behavior change and its effects. Evidence from outcome evaluations can be used for scale-up and long-term policy change.

Through process monitoring, we determine how and why the program was successful by assessing the reach, frequency of exposure, fidelity and package attractiveness to the target audience. These assessments are done at various stages, including before the program implementation and after the program implementation.

Dr. Prasad Gautam then introduced a monitoring mechanism called a post implementation monitoring survey (PIMS) that is conducted after the follow-up evaluation. PIMS is a monitoring process used to raise red flags about effectiveness of programs. This process ranks the sustainability status of projects into a single framework, evaluating cost-effectiveness and suggesting areas for improvement.

Moderated Panel Discussion and Key Takeaways:

A moderated panel discussion followed the presentations, diving deeper into various topics highlighted throughout the presentations and answering audience questions. Overall, the key takeaway from the webinar is:

• What gets measured gets done. Handwashing is too important to go through the motions of a program only to discover that it’s not effective. It’s important to plan M&E processes at the start of your project to ensure these processes are sufficiently resourced.
• Determine your indicators and the appropriate data collection methods. The way you measure handwashing is dependent on your overall objective. There are various methods to measure handwashing behavior and each method has its strengths and weaknesses, so it’s important to determine which method is best fit for what you’re trying to achieve.
• Assess and adjust. Monitoring and evaluation are an important part of program design and implementation. Practice adaptive management to allow for adjustments in response to changes in the target audience and environment, or in areas of programming that could be improved. Share key insights learned throughout the process.

The full webinar recording is available below.

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