DCHA Planning Framework

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USAID Office of Food for Peace ME WorkshopAug
20-23 / Aug 27-30, 2007
Measuring Hygiene Behavior Suggestions from the
Hygiene Improvement Project

Orlando Hernandez and Carol Baume Academy for
Educational Development
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Measuring behavior can be challenging!

• Some behaviors are sensitive or private
• Many behaviors are composed of sub-behaviors,
  each of which should be measured
• People not always consistent as to when and how
  they perform the behavior
• Difficulty of accurate recall
• Pro-social bias

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Another challenge

• Behavior change requires antecedent conditions.
• Hygiene behavior change requires facilities (e.g.
  latrines) or supplies (e.g. soap).
• ? Measuring hygiene behavior includes measurement
  of facilities/supplies as well as of the behavior

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BASIC BEHAVIOR CHANGE MODEL
EXPOSURE TO THE INTERVENTION -Radio -Demonstrati
ons -Posters -etc
CHANGE IN BEHAVIOR Correct HW at critical times
CHANGE IN BEHAVIORAL DETERMINANTS Internal
knowledge, at-titudes, perceived risk, outcome
expectation, norms, skills External supplies,
facilities, policies
CHANGE IN HEALTH STATUS Decreased diarrheal
morbidity Decreased diarrheal severity
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Main types of methodologies for measuring BC

• Self-report interview
• Inference/proxy spot check/observation of
  supplies or facilities, knowledge questions,
  skill demonstration, participatory methods
• Observation of behavior
• ? Each has strengths and weaknesses

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FFP - SAPQ Indicators for hygiene behavior

• caregivers demonstrating proper personal
  hygiene behaviors
• caregivers demonstrating proper food hygiene
  behaviors
• caregivers demonstrating proper water hygiene
  behaviors
• caregivers demonstrating proper environmental
  hygiene behaviors

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• The specific behaviors that comprise these
  indicators are to be defined by the Cooperating
  Sponsor in their ME plan and included as a
  footnote to the IPTT

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What are the key behaviors?
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Why these behaviors?F-Diagram

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Safe Feces Disposal
Handwashing
Safe Treatment Storage of Water
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HANDWASHING
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What is hand washing?

• Sub-behaviors
• Use running water
• Use cleansing agent (soap, ash)
• Lather / rub hands20 seconds
• 5 Critical times
• AFTER (risk of contact with fecal matter)
• defecation
• cleaning a child
• BEFORE (food handling)
• food preparation
• feeding someone
• eating

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HW Self Report

• Indicator washing their hands with soap at
  least x of the appropriate times during a 24
  hour recall period
• Do you have soap in the house?
• Did you use soap today or yesterday?
• What did you use it for? (Probe for specifics)
• Anything else?
• (see handout)

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HW Inference / proxy measure Spot check

• Pump, tap seen in house
• Stored or running water near latrine
• Cleansing agent near HW stations

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HW Inference / proxy measure Skill demonstration

• Running water used
• Soap used
• Hands rubbed / lather obtained
• for 20 seconds
• Indicator who washed hands correctly (met all
  criteria)

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HW Structured Observation

• Observe if hand washing actually happens
• By caretakers and family members
• At critical times
• Using standardized recording instrument
• During a standard period of time

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Observation Indicators

• of caregivers observed to wash hands with soap
  
• after using the toilet
• after cleaning child who has defecated
• before preparing food
• before feeding child
• before eating
• of caregivers observed to wash hands with soap
  at any of the critical times
• caregivers observed to have washed with soap at
  2 critical times

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Pros and Cons of Each Method
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Observation had been considered the gold
standard but

• In addition to implementation difficulties
  (intrusive, time consuming and expensive,
  difficult to train)
• Low reliability
• Repeat observations yield different results on
  different days
• HW decreases each consecutive day of observation

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• Can get different results depending on
  methodology but the difference may not be great
• Biran et al study high degree of correspondence
  between self report and spot check and possibly
  behavior

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Bill Gates will give us the answer!

• Gates-funded studies
• How reactive is a subject with respect to HW
  behavior, when observed during an extended
  observation?
• What is the optimum duration of a structured
  observation for the purposes of measuring HW
  behavior?
• Does hand contamination measured at random times
  predict hand contamination at times critical to
  pathogen transmission?
• What is the association between the presence of
  improved sanitation facilities and home hygiene?

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Use the same indicators each time you measure

• Even if an indicator/method gives you some degree
  of overestimation or underestimation, if you use
  the same ones over time, you will still have a
  good measure of the amount of change.

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TREATMENT AND STORAGE OF DRINKING
WATER
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Challenges of Water Treatment Safe Storage

• New and complex behavior
• Separate out drinking water
• Not current practice
• Lack of spare vessels
• Choose method/obtain
• Disinfect
• Protect

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Types of water treatment

• Filtration (various types)
• Chlorination
• Boiling
• Solar disinfection

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Measuring water treatment

• Chlorine residual testing (chemical testing)
• Is there a filter in the house? (spot check)
• Are solar disinfection bottles on the roof? (spot
  check)
• Where do they keep the boiled water (self report
  spot check)

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Indicator treatment of drinking water

• of households practicing effective drinking
  water treatment
• What is the main source of drinking water for
  members of your household?
• Do you treat your water in any way to make it
  safer to drink?
• What do you usually do to make the water safer to
  drink?
• (See handout)

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Water storage containers should have

• Narrow neck
• Hard covers, caps
• Spigot

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Indicator storage of drinking water

• of households correctly storing drinking water
• How do you store drinking water?
• If in containers May I see the containers?
• Observe characteristics of container.
• Observe if container covered.
• (See handout)

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SANITATION
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Improved and Unimproved facility according to
MDGs

• Improved
• Flush or pour flush to piped sewer system, septic
  tank, pit latrine
• Ventilated improved pit latrine
• Composting toilet
• Unimproved
• Flush or pour-flush to street, yard or plot
• Open pit without slab
• Bucket
• Bush

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Measuring sanitation improvement

• A sanitation program will have to decide if it is
  enough to move up the ladder, or if it wants to
  attain a certain percentage of households having
  an improved facility.

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Sometimes there is a sanitation facility but

• It is not hygienic (has feces on floor or wall,
  has many flies, poorly ventilated)
• Children do not use it / caregiver does not
  dispose childs feces there
• It is used very little by anyone

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Sanitation self report and spot check

• Please show me where you go to defecate.
• Observe Is stool visible on the slab, floor, or
  walls?
• Is this toilet shared with any other household?
• Is water available for handwashing in/near the
  toilet structure?
• Please show me where child usually defecates.
• If child does not defecate in toilet Where are
  the childs feces usually disposed?
• (See handout)

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Wrapping up hygiene behaviors

• Few standard indicators because there is a wide
  range of behaviors
• Require facilities/supplies to carry out
• Difficult to measure accurately, but often some
  simple indicators can give you an acceptable
  estimate for your needs.

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Summary of process for PMP

• Define the specific behaviors and sub-behaviors
  you are promoting in your setting and program.
• Measure facilities/supplies as well as the
  behavior.
• Select indicators and methodologies that are
  feasible for your organization to use. This
  usually means well-crafted survey questions with
  spot checks incorporated into the instrument.

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To ease your mind

• If you use the same indicators over time, you
  should get an adequate measure of the amount of
  change which tells you whether your activities
  are effective and that is probably what you are
  most interested in.

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Setting targets

• How long does it take to change behavior?
• What targets should be set?
• What amount of behavior change should we expect?

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• It depends. (sorry)
• Relative advantage
• Complexity, skills
• Norms Do you think other people are doing it?
  Do you think others expect you to do it?
• Compatibility with existing beliefs and values
• Observability of positive results - preventive
  behaviors difficult to instill distal results
  not as motivating as proximal
• Affordability/accessibility of resources,
  supplies
• Intensity of your intervention

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S Curve Amount of change to expect also depends
on where you begin on this curve (tipping point)