Structured observations are considered the best way to measure handwashing. Structured observations of household handwashing behaviour require an observer to be present in the household for several hours (typically between 3 to 7 hours) at a time when the target behaviour is most likely to be performed. The observer takes note of:
Potential opportunities for handwashing (e.g. before eating a meal).
Whether or not the person/s of interest washed their hands at these opportunities.
Whether or not the person/s of interest used any cleansing agents (e.g. soap or ash).
Observation results are summarised by calculating how many times hands were washed with soap out of all the available opportunities for handwashing. A step-by-step process for doing observation is described in this document.
Benefits of Structured Observation:
Allows you to observe how people conduct a behaviour in the course of daily life rather than relying on what they report they do.
Provides an opportunity to collect data about numerous individuals at once.
Allows you to understand how the behaviour fits within broader daily routines.
Allows you to collect information on frequency of handwashing behaviour and also thoroughness of handwashing (technique, time, products etc.)
Limitations of Structured Observation:
The presence of an observer may result in participants acting differently, for example, they may practice better handwashing behaviours because they know it is a socially desirable behaviour. It is therefore critical that the participants do not know that the observation is specifically focused on handwashing behaviour. When communicating about the study to the participants (e.g. during the informed consent process) the data collector should explain that the purpose of the observations is to gather information about daily routines and other household practices.
Structured observations are labour and time intensive. They require observers to be well trained and, depending on the time of day you want to observe and the duration of the observation, one observer can typically only gather data on one household per day. In a large programme it may be appropriate to collect data through other means and only conduct observations in a subset of households and triangulate the data from all sources.
In some settings, extended families live in large compounds with multiple buildings. This can make it challenging to observe all handwashing opportunities for all household members. Observers need to know whose behaviour is most important to document. Criteria may need to be developed to determine when it is necessary to station more than one observer in a household.
Participants may find the idea of a stranger in their household uncomfortable. This can be minimised by involving young female observers who in most cultures are seen as a less threatening or judgemental presence. Decisions about who to employ should be context-specific and the safety of the enumerators should be paramount.
During the COVID-19 outbreak it may not be possible to conduct structured observations if movement restrictions are in place. Additionally, spending long durations of time inside a household is likely to put staff and community members at risk of infection.
Acceptability for this data collection method may also be low among the community at this time given people’s fear about COVID-19.
Recommendations for use during COVID-19
Due to the risks of infection presented by having observers spend long durations of time inside a household, it is not recommended that household structured observations are used during COVID-19 response programming until national guidelines permit people to go inside other’s houses. In those cases, it will be important to ensure observers are able to travel safely to the data collection sites, that they have appropriate protective equipment (e.g. masks), that they maintain a safe distance from household members during the observation, and they do not consume any drinks or food during the observation period.
Note that it may be possible to conduct structured observations at public handwashing facilities instead, or in addition to, structured observations in households.
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