In disease outbreaks and crises, implementing organizations are often under pressure to act quickly and begin project implementation right away. Sometimes this urgency results in choices that compromise the way projects are designed and implemented, with potential negative effects on the acceptability, effectiveness and sustainability of projects. In this resource, we provide general suggestions for the designing of hygiene behaviour change projects that can serve as a template for local adaptation and customization. We also outline the things that may need to be adapted given the nature of specific diseases.
The purpose of this resource is to provide general guidance on the process of hygiene behaviour change intervention development. The image below visually depicts a process for designing hygiene promotion projects with three simple steps. Each step is described in detail below.
Source: Sian White
We developed this resource primarily based on evidence and experiences related to handwashing project design. However, the process we describe is just as applicable to other preventative behaviours, such as physical distancing behaviours and mask use.
The process above aligns with various behaviour change models and frameworks that describe a process for designing behaviour change interventions. For more information on these stages, we suggest some of the following resources:
COM-B as applied to COVID-19
How to incorporate guidelines, theory and evidence throughout the programme design process
Before beginning to design your project, take time to assess global and national guidelines in relation to the focal disease and hygiene projects and policies in your country. Existing guidelines will provide initial indications about which behaviours are important for the prevention of your focal disease. See the following for some examples:
Cholera: Global Task Force on Cholera Control – road map, dashboard, guidelines and tools
Evidence-based and theoretically informed hygiene projects have been shown to be more effective than traditional education only approaches (Study 1, Study 2, Study 3). When designing a hygiene behaviour change project, understanding the basics of behaviour change theory and its application to hygiene projects can be helpful. These Hygiene Hub resources might be useful during this step:
Where possible, existing research or reports about key preventative behaviours in your local context should be reviewed. There are also a number of systematic literature summaries relating to well-studied behaviours, like handwashing, that can help inform your organizations approach to changing behaviours. Reviewing and understanding current literature will help in identifying the diverse factors that can influence individuals' behaviours. Learning from existing literature can help save time at other stages of the project design process. It will also avoid you repeating data collection on some topics.
In the initial stages of intervention development, it is also useful to connect with other organisations involved in the disease outbreak response in your country and ensure that efforts are coordinated and complementary. Find out what they are working on and whether they already have information on preventative behaviours. The following resources can guide efforts to coordinate and connect with other organizations:
Step 1: Selecting target behaviours, populations and settings
Step 1 of our three step process for hygiene programme design requires clearly defining the behaviours your project intends to focus on. If you are struggling to decide which behaviours to promote, focus on behaviours that have a known public health benefit, that are being recommended or prioritised by the government in your settings, and behaviours that are adapted in such a way that they are feasible to do for populations. Key preventative behaviours during COVID-19 relate to handwashing with soap, cleaning and disinfecting surfaces, physical distancing and mask use. It will be useful to refer back to global and national guidelines during this step.
When defining a behaviour, be clear to state who needs to do what, where, when and how. This process is often referred to as segmentation. This means that defining your target behaviour as ‘handwashing with soap’ is not specific enough. Instead definitions for target behaviours, such as handwashing with soap, can be written out as follows:
Who: all members of the population, including groups like children, people with disabilities, or poorer segments of the population who may find regular hand washing more challenging.
What: handwashing with soap or alcohol-based hand rub.
Where: at home and in public locations such as in schools, healthcare settings, marketplaces and religious sites.
When: at times that are important for interrupting disease transmission. For instance, taking COVID-19 as an example, key times might include: after coughing or sneezing, when entering or leaving the household or any other building, after coming into physical contact with anyone outside your household, after touching surfaces when outside the home, after visiting a public space such as public transportation hubs, markets and places of worship, and before, during and after care of a sick person. Additionally, you should target standard critical times for interrupting faecal-oral transmission, such as: before food preparation, before eating food or feeding a child, after using the toilet and after cleaning a child’s bottom.
How: for at least 20 seconds, rubbing all parts of hands thoroughly and creating a good lather with the soap.
Describe behavioural attributes:
During this stage of programming, it is also useful to define the specific attributes of the target behaviour. Behavioural attributes refers to the characteristics of the behaviour itself. For example:
Do you want people to practice a behaviour or stop practicing a behaviour?
Is the behaviour new or unfamiliar?
Is the behaviour routine or one-off?
What can be done to make the behaviour feasible in the context?
For handwashing, remember that handwashing is not a new behaviour - most people know or understand how to wash their hands. However, for some diseases, we may be asking people to wash hands at new times. Handwashing also happens on a regular, routine basis and is dependent on access to infrastructure and supplies. Making handwashing feasible to practice in some contexts may involve looking into low-cost soap options, how to practice handwashing when water is scarce and how to handwashing infrastructure.
On the other hand, certain preventative behaviours like physical distancing adopted during the Ebola and COVID-19 outbreaks were new in all cultures and required us to stop behaviours that we were used to doing. This required social norms to be challenged. For example, during the height of the COVID-19 pandemic, people around the world were asked not to hug, kiss, or shake hands as part of greetings and instead adopt new, non-contact modes of greeting each other. At the start of the outbreak, safe mask use was another new behaviour in most countries, too. With both of these behaviours, substantial contextualisation was necessary to make sure these behaviours were feasible to practice in resource limited settings.
Define target audiences and settings:
Many water, sanitation and hygiene projects are designed to reduce diarrhoeal diseases. For this reason, key target groups are often caretakers of children under the age of 5. However, everyone is susceptible to outbreaks of infectious diseases, such as COVID-19, and those most at risk of developing serious symptoms are older adults and people with health conditions. As such, we need to ensure that the whole population practices key prevention behaviours, including people who feel healthy.
When defining your target audience, it is also important to define the setting where you would like to see changes in behaviours. Many hygiene programmes are targeted at the community level. However, if you plan to work in schools, health centres, workplaces or public settings like markets, then it is useful to identify this early on, as the factors that determine preventative behaviours may be different in each of these settings.
There are several advantages to clearly defining the behaviours, target groups and settings. It will help guide your research and investigation - allowing you to be more aware of potential barriers and enablers. It will also guide which behavioural products are needed to practice behaviours (e.g. for practice handwashing this may include handwashing facilities, soap, water in key locations). Specificity will also help you communicate clearly to populations and avoid messages that are difficult for populations to act upon (e.g. a message like ‘maintain good hygiene’ is not clear enough to act upon).
Step 2: Learning from populations about behavioural barriers & enablers
Step 2 of our three step process for hygiene programme design requires learning from communities about all of the factors that influence the behaviour you are interested in. This step is often called ‘formative research’ because it informs the project you will design. As this article explains, there are many determinants for hygiene behaviours. Formative research should be guided by theory and build upon existing evidence about the target behaviours. When designing formative research methods, consider determinants other than just knowledge, fear and misconceptions. When assessing behavioural determinants, it’s best to use a range of qualitative and quantitative methods.
Learning from populations can be challenging during infectious disease outbreaks given that person interactions are often minimised. In this document we describe a range of ways that you can continue to engage with and learn from communities in these instances. Our resources on monitoring and evaluation also provide some guidance on how to do data collection remotely and highlight some of the strengths and limitations of different approaches.
During outbreaks it is easy to assume that the need to act quickly is more important than taking the time to learn from communities. However, when project implementers have reflected on previous outbreaks, the lack of learning from communities early on is often cited as a missed opportunity. Even a short period of learning is better than not allowing time to learn from populations at all. Your research can be complemented by other research conducted locally or globally about the target behaviours.
Approaches have also been developed to do this community consultation process rapidly. For example, the Wash'Em process provides a set of rapid assessment tools designed for crises and outbreaks that take a matter of days to complete. This is complemented by programme designer software that generates suggestions for context-adapted activities. Having said this, it is also possible to start doing simple ‘quick-win’ and low-risk activities from early on in the outbreak response. In these two resources (infrastructure, and behaviours), we provide some examples of handwashing related activities that are easy to do and appropriate for all contexts. While these initial actions are taking place, your organisation will have time to learn from populations so that you can design a more comprehensive and adapted package of actions.
Step 3: Identifying appropriate behavioural techniques and delivery channels
Step 3 of our three step process for hygiene programme design requires organisations to think about how they will actually bring about behavioural change (i.e. by identifying behaviour change techniques) and how you will reach your target population (i.e. by identifying appropriate delivery channels.
What are behaviour change techniques:
Behaviour Change Techniques (BCTs) are the active ingredients of your project. BCTs focus our attention on the content of what we will do, whereas discussion on delivery channels is all about how this will be done. The RANAS model and the COM-B both provide detailed lists of BCTs. Commonly, implementing actors struggle to link their formative research findings with BCTs and then develop these into detailed activity descriptions that can be implemented in the programme setting. The following models provide additional guidance on how to make this transition: the RANAS process, Wash’Em and Designing for Behavior Change. The diagram below shows a worked example of how formative research findings on handwashing behaviour are translated into BCTs and BCTs are used to develop project activities.
Defining delivery channels:
Work with communities to map out all of the ways you could reach them and share information with them during outbreaks. You can do this through a simple brainstorming exercise as shown in the image below:
Source: Sian White / LSHTM
For a more structured approach, try using the Wash’Em ‘Touchpoints tool’, an example of this in action is shown in the video below. Note that this video was done in-person. To adapt this method you could try conducting online group discussions or you could bring people together in an outdoor space and make sure that physical distancing is maintained during the session and that people wash their hands with soap before and after the session.
When deciding which delivery channels to use, consider the following:
Safety: Use national guidelines to assess whether it will be possible for your staff to use delivery channels which involve in-person interactions. Where possible, make sure to include some delivery channels which are non-contact or have minimal contact. Examples include radio, television, social media, printed materials or loudspeaker announcements. Consider how you might adapt your delivery channels at different stages of the outbreak.
Reach: Which delivery channels are available to the majority of people within your population? If you are considering using mass media, you might also want to pay attention to which stations people tune into and at what times. If you are working in an area where people have access to social media and the internet, find out the websites and social media sites that are most commonly used and trusted, and how they are used within the culture.
Accessibility: While overall reach is important, it is necessary to also consider which delivery channels are most appropriate for different sections of the population. Women and girls, older people, people with disabilities, people with pre-existing medical conditions, people living in rural areas, and other groups who might be vulnerable to discrimination and exclusion are all likely to be harder to reach through most delivery channels. To overcome these challenges, it may be necessary to actively engage these populations to identify their preferences and tailor materials to their needs. This document from UNICEF provides some guidance on how this can be done for people with disabilities and this document from IFRC provides guidance on engaging and communicating with older people. Note that whilst the aforementioned resources are specific to COVID-19, principles and activities can be applied to other infectious diseases.
Credibility and trustworthiness: Which communication channels or individuals do people trust or respect? Exploring this with communities may challenge common assumptions about what constitutes reliable public health information. For example, a study among Rohingya refugees living in Bangladesh found that trusted sources of information during outbreaks included trained community leaders, such as imams and women’s group leaders. Information from these sources was preferred over health and aid workers who are not always seen as trustworthy and are sometimes misunderstood. Refugees also trusted members of the Rohingya diaspora, rather than public health information shared by local news services, as Bangladeshi and Burmese news services were seen to stigmatise refugees and even legitimise violence against them. This mask intervention in Kenya used a number of trustworthy delivery channels, including community health workers and role models who were considered “trustworthy in health measures” by community members. For more information about source credibility, see this article.
Influence and persuasion: Certain delivery channels or sources of information may not be seen as credible or trustworthy, but may still be persuasive or influential. For example, many people know to question the credibility of information they see on social media. However, there are still a whole range of reasons why people might find social media posts influential and persuasive. For instance, this intervention study included a YouTube video of a Dutch social media influencer interviewing a renowned virologist on the importance of COVID-19 preventive behaviours. The persuasiveness of information often depends on its design, the content and format (e.g. photos and videos may be more persuasive than text alone), whether the message resonates with your beliefs and values and who the information is shared by within your social network. For more information about persuasion, see this resource.
Avoid relying on any one delivery channel. Interventions that use a range of delivery channels to engage and remind populations are typically more successful in changing behaviour. Here are some examples demonstrating the value of multiple delivery channels: Study 1, Study 2, Study 3 and Study 4. For more information on selecting the right delivery channel, see our resource here.
Bringing theory, evidence, formative research, BCTs and delivery channels together to design an intervention
During our three-step process of hygiene project design you will have gathered lots of information about behaviour, your context, your populations and the opportunities that are available for delivering your programme and changing behaviour. All of this information should be brought together to inform a preliminary outline of your context-adapted behaviour change programme. When thinking about how all these components can be combined to inform creative project ideas, it can help to draw on a range of expertise. This could include engaging creative agencies, members of your target population, WASH and behaviour change experts and those who will be involved in delivering the project.
For more information on how to creatively design hygiene projects, follow the tips or follow the steps described in the webinar below.
Source: LSHTM & WaterAid
Further reading / support:
Ongoing adaptation and improvement to hygiene programmes
Once you have followed the three step process for intervention design and have developed an initial draft version of the project plan, the following steps should be undertaken to improve the feasibility and acceptability of the project:
Pre-testing - Pilot project ideas with a small group of the population. It can be useful to do pre-testing when ideas are still quite rough so that there is still time to implement the adaptations. Take time to learn from the population about how they interpret the messages or activities, whether anything is unclear, whether the messages and activities seem relevant to them, and how the project materials and the approach used makes them feel. Adjust materials and project activities based on this feedback.
Develop an implementation guide and train and learn from staff - It is important that your staff know how to carry out each of the activities being proposed during the project. We recommend developing a draft manual to guide the implementation of each component. This should include information on what materials are needed for each activity, how long the activity will take, when it should happen, who it should be delivered by, and detailed step-by-step instructions for how it should be done. Train staff on each component of the project and about safety measures at this time. Take time to learn from them about how the project might need to be adapted to make it more feasible for them to carry out. Incorporate this feedback and finalise the project manual.
Develop a monitoring and evaluation strategy - Consider whether your implementation, staffing or budgeting needs to be adjusted to allow effective and safe monitoring and evaluations processes. Plan for how data will be used to iteratively adjust and improve the project. Given the changing nature of outbreak response, it is useful to assume that on a monthly basis (at least) you may need to make revisions to the project (normally these will be relatively small). In order to do this, establish means of generating ongoing community feedback. Organise weekly meetings with the implementation teams to learn more about what is working well and what is challenging and collectively decide on any programme adjustments.
Author: Sian White