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Monitoring handwashing behaviour

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By Jelena Vujcic, dept. of social and preventive University at Buffalo, Buffalo, NY, USA. Prepared for the Monitoring sustainable WASH service delivery symposium, Addis Ababa, Ethiopia, 9-11 April 2013.

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Monitoring handwashing behaviour

  1. 1. Monitoring Handwashing Behavior Thursday, April 11th, 2013 Monitoring Sustainable WASH Service Delivery Symposium, Addis Ababa, Ethiopia Jelena VujcicDept. of Social and Preventive Medicine University at Buffalo, Buffalo, NY, USA
  2. 2. Overview• Why monitor behavior? Shifting paradigm for handwashing programming and monitoring• Current indicators used to measure handwashing behavior – Utility, strengths, limitations• Measuring behavior at scale
  3. 3. Handwashing promotion at a glance… Ben Nygren Pavani K. Ram
  4. 4. Major goals of handwashing promotion programs
  5. 5. A shifting paradigm in handwashing programming/implementationSupply-driven Demand-drivenInfrastructure focused Behavior-focusedGovernment and support Room for private sector to respond toagents as main drivers of household demandschange Government and support agents facilitate communities’ change process van der Voorden, Keynote paper …and a shift in monitoring methods and actors
  6. 6. Input Core human and financial ex. Number of health workers resources required to develop the hired program for implementationProcess Activities and efforts ex. Health worker visits to Monitoring implemented to achieve program homes goalsOutput Direct results of the efforts at the ex. Number of soap bars program level distributedOutcome Effects of program outputs at the ex. Increased proportion of population level mothers who wash hands with soap at critical timesImpact Effects of program at the ex. Reduced risk of diarrheal population level with adequate disease account of other factors
  7. 7. Why monitoring handwashing behavior is important/relevantEvidence from research Knowledge only Necessary but not sufficient for practice Hardware only• Old habits are hard to break, new habits are hard to makeRole of behavior in prevention, in health, in selfempowerment, in equity is clear• Without behavior do we have a complete picture of what the program achieved at the population level?
  8. 8. How is handwashing behavior measured?
  9. 9. Indicators PROGRAMGOAL COMPONENT INDICATORS DATA COLLECTION METHODAdvocacy Outputs (A1) Number of handwashing promotion advertisements distributed/broadcasted Program records/Media tracking (A2) Number of handwashing promotion events Program records/Monitoring (A3) Number of participants at handwashing promotion event(s) Program records/Monitoring (A4) Number of stakeholders introduced to benefits of handwashing with soap Program records Outcomes (A5) Recall of the event/advertisement Survey (A6) Recall of the main message(s) from an event/advertisement Survey Impact (A7) Progress toward commitments Program records (A8) Number of commitments (funding, sponsorship, participation) Program recordsEducation Outputs (E1) Number of education related events Program records Outcomes (E2) Knowledge of the benefits of handwashing with soap Survey (E3) Knowledge the critical times for handwashing Survey (E4) Soap use during a handwashing demonstration (also a proxy indicator of Behavior Change) Rapid observation Impact (B2-6) Behavior change as measured by indicators listed below (see below)Behavior Outputs (B1) Number of behavior change communication events Program recordsChange (B2) Number of participants at behavior change communication events Program records Outcomes (Proxy indicators) (B3) Soap and water present together at a handwashing place Rapid observation (B4) Soap present in the household Rapid observation (B5) Hand cleanliness score (visual inspection of hand cleanliness) 3-pt. hand inspection (Self-reported behavior) (B6) Self-reported handwashing with soap at any critical event/at specific critical event Self-report (Direct observation of behavior) (B7) Observed handwashing with soap and water at any critical event/at a specific critical event Structured observation Impact Prevalence of illness during the 72 hours preceding interview (e.g. diarrhea, or respiratory illness) Morbidity survey
  10. 10. Indicators PROGRAM DATA COLLECTIONGOAL COMPONENT INDICATORS METHODBehavior Outcomes (Proxy indicators)Change Soap and water present together at a handwashing place Rapid observation Soap present in the household Rapid observation Used in (Self-reported behavior) MICS/DHS Self-reported handwashing with soap at any critical event/at Self-report specific critical event (questionnaire) (Direct observation of behavior) Structured observation Observed handwashing with soap and water at any critical event/at a specific critical event
  11. 11. Limitations and StrengthsIndicator Limitations Strengths(Proxy indicators) • As a proxy, cannot tell us • Relatively quick and simpleSoap and water present together at how often hands are to collecta handwashing place washed, if soap or other • Easily incorporated in materials are used to wash surveysSoap present in the household hands, when hands are • Validated against direct washed observation of behavior • Scalable, used in MICS/DHS(Self-reported behavior) • Over reports handwashing • Relatively quick and simpleSelf-reported handwashing with behavior to collectsoap at any critical event/at specificcritical event(Direct observation of behavior) • Resource and time intensive • Direct observationObserved handwashing with soap • Hard to do at scale • Rich detail regardingand water at any critical event/at a • Reactivity behaviorspecific critical event
  12. 12. Is monitoring behavior feasible at scale?• Using proxy indicators at scale is feasible – MICS and DHS indicators will give us key insights to behavior at the global and regional levels• Structured observations are difficult to scale, however…. – Using representative sub-sets of the target population to supplement proxy indicators – Using a partnership approach can provide support for larger scale (Nepal case study)
  13. 13. Direct observation of behavior at large scale -Nepal Case Study• National handwashing promotion program – Supported by Nepal’s Private-Public Partnership for Handwashing – Government-lead implementation – Technical, resource and funding support from partners – Capacity building, mass media, door-to-door visits at community level, school- based promotion• Clear behavioral objectives – MICS/DHS handwashing indicators needed to be supplemented by structured observation• Robust monitoring and evaluation plan (UNICEF, UB) – Structured observation in approximately 1,100 households across geographical zones
  14. 14. Today’s discussion• Value of monitoring behavior• Examples from implemented programs• Challenges• Ways forward• Gaps we still need to address
  15. 15. Resources• UNICEF M&E module for programs the promote handwashing• Practical guidance for measuring handwashing behavior ( Practical-Guidance-Measuring-Handwashing-Behavior-2013-Update.pdf)• Global Public-Private Partnership for Handwashing (