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Designing a theory and evidence-based COVID-19 prevention programme that is feasible within a refugee camp
Designing a theory and evidence-based COVID-19 prevention programme that is feasible within a refugee camp

A case study by UNHCR, World Vision and Ranas in Zimbabwe

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Updated over a week ago

Country and region: Chipinge District in Manicaland Province, Zimbabwe

Organisation: Partnership between UNHCR, World Vision, RANAS Ltd and SDC

Point person and Role: Max Friedrich (Behavioural Change Expert at RANAS Ltd.) Jay Matta (UNHCR HQ WASH Team).

Population served by the programme: 14,500 refugees predominantly from the Democratic Republic of Congo living in the Tongogara Refugee Camp.

Unique characteristics of the setting: Long-established camp (since 1984) currently hosting approximately 14,500 People of Concern (PoCs). Chipinge District is remote and prone to natural disasters such as droughts and flooding.

Number of cases and deaths due to COVID-19 at time of publishing: 6,559 cases and 203 deaths (in Zimbabwe).

Image: A World Vision field worker conducting a qualitative survey with a camp resident.

Briefly describe the key components of your COVID-19 response programme

UNHCR, World Vision and RANAS Ltd. came together in April 2020 to design a theory-driven evidence-based behaviour change intervention aiming to increase handwashing with soap (HWWS) and physical distancing among Tongogara Refugee Camp residents in response to the COVID-19 pandemic.

The intervention is a multi-component programme composed of:

Households visits by trained health promoters from the camp. During these visits, the following campaign messages will be communicated:

  1. Keeping a physical distance (PD) away from others and handwashing with soap (HWWS) at key times reduces the spread of the coronavirus

  2. Important others are doing this (PD and HWWS) every day

  3. Important others want you to do this every day

  4. You can do it

  5. You can become a good example, too - help others to keep PD and HWWS and tell them about the benefits. For example, promoters will read open letters signed by the local leaders, highlighting their commitment to HWWS and physical distancing. These messages are complemented by self-regulation exercises such as goal setting and barriers planning.

Construction of additional water points in the camp and installation of tippy tap handwashing stations in key public places such as markets, churches, and houses of local leaders, so leaders can be role-models of appropriate handwashing behaviour.

Reinforcement of key messages using loud-speakers and posts on social media.

What process did you use when designing your COVID-19 response programme?

Our programmatic aim was to increase both handwashing with soap and physical distancing (defined as maintaining at least 1m distance from people outside of your household) among camp residents. To design our behaviour change intervention, we used the Risks, Attitudes, Norms, Abilities and Self-regulation (RANAS) approach, developed to change behaviour in the Water; Sanitation and Hygiene (WASH) sector in low and middle-income countries. We followed the three phases described in the RANAS approach to design our intervention:

  • Phase 1: We conducted qualitative interviews to identify potential behavioural and contextual factors associated with our target behaviours. The goal of Phase 1 was to assess the project context and to inform the quantitative survey that would be conducted in Phase 2. To assess our intervention context, we conducted 5 face-to-face qualitative interviews with key stakeholders and 10 with camp residents to understand the everyday realities of living in the camps. We explored existing water-related behaviours such as water collection, water storage, existing hand hygiene practices, as well as movement patterns and daily routines.

  • Phase 2: We used the qualitative insights to develop and adapt a quantitative survey which was designed to measure behavioural determinants associated with our target behaviours. This survey was conducted with 200 camp residents using tablet computers and KoboCollect data collection software. In the first section of our survey, we measured existing practices of handwashing with soap at critical COVID-19-related times and physical distancing in key situations. For instance, we asked about HWWS when leaving or entering home, after coughing or sneezing, and about keeping a physical distance of 1 metre when meeting friends, going shopping, or walking in the street. In the second section of our survey, we asked several questions to measure the RANAS behavioural factors. By correlating behaviour and behavioural factors, we identified those factors most strongly associated with behaviour. Social norms and self-regulation (i.e. a person’s attempts to plan and self-monitor a behaviour and to manage conflicting goals and distracting cues) factors were identified to be most strongly related to HWWS and physical distancing in this setting.

  • Phase 3: Phase 3 is the intervention design stage. Based on Phase 1 and Phase 2 findings, we decided our intervention should position HWWS and physical distancing as a social norm and strengthen the population’s self-regulation. We used known behavioural change techniques (compiled in the RANAS catalogue of BCTs) to design the intervention content which, as described above, included household visits, signed letters and role-modelling by influential leaders, etc..

We are planning to implement our intervention in the coming months, starting with the training of health promoters from the camp alongside the pilot-testing of the intervention content within a small sample of households.

A World Vision fieldworker conducting a quantitative interview.

What is one thing that has been working really well so far and is there something other programmes could learn from this?

NB. This section will be updated after intervention delivery (by the end of 2020) to describe the behaviour change outcomes of the intervention and reflects on potential success.

Responses to the COVID-19 pandemic needs to be tailored to local contexts and based on evidence. Using the existing RANAS approach has allowed us to design an intervention fulfilling these criteria. RANAS is a straightforward, step-by-step, and theory-driven methodology which has already been used to design successful behaviour change interventions, including handwashing practices. At the same time, this approach provides the opportunity to develop interventions which are tailored to the local contexts.

What is one challenge that you have encountered and how are you trying to overcome this?

Developing our handwashing and physical distancing programme has been one project among many others implemented in the Tongogara Refugee Camp since the start of the COVID-19 pandemic. Managing competing priorities and staff workload has been one of the main challenges of our implementing partners. Whereas designing behaviour change interventions using the RANAS approach usually takes a few weeks, conducting qualitative and quantitative surveys still requires human resources and time, it was not always possible to allocate resources adequately to this specific project. To develop this intervention, it took us almost five months from the start of the formative research to the end of intervention design.

How have you been engaging communities throughout your programme and what feedback have you received?

The implementation of the intervention has not yet started, so we have not received feedback on the content of our programme. Regarding the intervention content, we are planning to combine the training of our promoters with the pilot-testing of the intervention materials in a few households. Feedback from households will be collected by both promoters and trainers and adjustments to the intervention content will be made accordingly. Following the pilot-testing, the intervention will be delivered in half of the camp first. An evaluation survey will then be conducted to measure change in the behavioural factors and the subsequent effect on the target behaviours. After the survey all remaining camp sections will be targeted. We will also collect feedback on the acceptability of the intervention content and delivery.

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