This brief summarises key strategies to ensure inclusion of vulnerable people when both planning and implementing COVID-19 (and other infectious diseases) prevention and response programmes in low- and middle-income countries (LMICs). The brief covers:

The brief is mainly for organisations working to improve hygiene-related behaviours such as handwashing with soap and water, safe water chain practices when collecting and storing drinking water, and latrine use. These will be largely (but not exclusively) within the Water, Sanitation and Hygiene (WASH) sector. It is also useful for public health-related behaviours such as mask use and vaccine uptake.

This brief is based on the lessons from two rounds of programming funded by the Hygiene and Behaviour Change Coalition (HBCC); from individuals working within the WASH sector and a desktop review of publications about the pandemic response. We include direct quotes where possible, giving the organisational source rather than named individuals.

Vulnerability is a key concept to consider when designing and implementing infectious disease programmes, as it can influence health outcomes and healthcare access among other factors. Moreover, crises typically make existing vulnerabilities and power imbalances worse. People with poor health also suffer more in disease outbreaks than people in good health, increasing the health divide.

Whilst there has been an increasing focus on vulnerability within the global health sector in recent decades, there is no universal definition and approaches to the term vary. This can cause confusion and impede evidence-based learning, contributing to the pattern of response programmes failing populations who may be vulnerable e.g., COVID-19, natural disasters and Ebola.

Whilst there are numerous definitions, it is generally accepted that vulnerability is a dynamic and multifaceted phenomenon, which operates across multiple dimensions. In the health sector, it is typically conceptualised as either a determinant of poor health or a barrier to achieving good health. The concept is inextricably linked to the notion of power and populations experiencing high rates of vulnerability are invariably difficult to reach, under supported and “invisible” due to inadequate data.

For the purpose of this resource, we will define vulnerability as “the degree to which a population or an individual is unable to anticipate, cope with, resist and recover from the impacts of disasters. It is a function of “susceptibility and resilience” (WHO). This definition speaks to the fact that vulnerability is considered to be the “human dimension of disaster” and is both a driver and outcome of risk. See this page from the United Nations Office for Disaster Risk Reduction (UNDRR) for further information.

As the formula demonstrates (Image 2), vulnerability is influenced by hazard and exposure and can be developed through various routes. For instance, people with pre-existing health conditions have a higher hazard response to SARS-CoV-2 as they are more likely to develop serious complications. Groups who are prone to exclusion and discrimination also have a higher hazard response. Others might experience disproportionately high exposure to the virus – for instance, frontline health workers. Then you have groups who have both a higher hazard and exposure response, such as migrant workers, female health workers or older people, who are at risk of severe complications and face exposure via carers and health workers. It is important to understand how vulnerability is developed in these groups, as different responses are required.

For further insight on defining and conceptualising vulnerability, see our resource here.

Programmes working to improve hygiene related behaviours (largely, but not exclusively, WASH programmes) to prevent and respond to pandemics should be inclusive of populations who may be vulnerable from the start and continue to be inclusive throughout because:

WASH programmes to prevent and respond to COVID-19 and other infectious diseases need to continually assess human vulnerability. This ensures that all groups who may be vulnerable can be identified and engaged with, and resources are allocated effectively.

We have identified a number of lessons for including people who may be vulnerable. These are useful when planning and implementing WASH programmes to prevent and respond to COVID-19 and other infectious diseases. These are:

When organisations are committed to inclusivity, carefully considering vulnerability at every step of the process is key. This helps identify people who may be vulnerable when you are planning and implementing programmes. Inclusion then simply becomes “a necessary part of the content creation process” with “processes set-up to address (roadblocks or challenges)” (International Non-Governmental Organisation, INGO).

Organisations who have clear budgets for standard work processes and tools such as the COVID-19 Inclusive WASH Checklist (Case Study 1) will be better positioned to prevent and respond to infectious diseases such as COVID-19. In such organisations, “designing a COVID-19 prevention and response programme (does not) demand any different approach to vulnerable populations than regular WASH programmes - but with the caveat that definitions of vulnerability may be different in a COVID-19 programme” (INGO).

Ensuring integration, developing staff

Policies, tools and budgets are necessary, but to ensure that team members have the knowledge and skills required to identify groups who may be vulnerable, at the organisational- and community-level is key. The timing of the training is important: ideally, team members will receive training on joining an organisation, and the start-up phase of programmes should also allocate time for training if needed (for example, for new programme-specific team members, or as a general refresher). Having tools in place to share continuous learning on inclusion can also support mindset shifts within an organisation.

There are (free) online courses available, for example, Kaya’s Introduction to Needs Assessments in Emergencies and Equality, Diversity and Inclusion. Some organisations may choose to have in-house training courses (see Case study 2). These can be opened to partners such as community health workers if needed.

The need for training was also noted in the evaluation of HBCC interventions for people with disability, older people, and caregivers in Bangladesh, Kenya, Indonesia, Sierra Leone and Zambia. The evaluation concluded that:

a) Program staff involved in intervention design need intensive training on disability and ageing inclusiveness; and

b) Staff involved in intervention delivery and monitoring need project and intervention-specific training on considering disability and ageing during intervention delivery.

Research noted that HBCC-1 interventions were less inclusive for people with disabilities and older people than for people without disabilities or who were younger (Case study 3). The funding mandate for HBCC-1 projects did not specifically tell organisations to include people with disability and older people.

Engage funders and funding

Drawing on the lessons from HBCC-1, HBCC-2, partners were asked by the donor to place a greater emphasis on the inclusion of populations who may be vulnerable to COVID-19 or at higher risk of contracting, being ill and dying from, the disease. One project partner appreciated such direction. They found that it supported internal advocacy efforts to promote the inclusion of populations who may be vulnerable as “when you … say the donor is thinking this is really important, and to say that from day one very, very firmly, even as we’re signing the contract, is helpful” (INGO).

Measuring inclusion

However, as one project partner stated, “vulnerability needs to be defined at the local level” and “adopting a standard definition of vulnerability across different geographic locations [should be avoided]” (INGO).

It is therefore suggested that project mandates specify the need for inclusivity and define vulnerability criteria but leave project partners to subsequently identify local populations who may be vulnerable within their programmes. Funders should embed accountability measures in project reporting requirements throughout the life of the programme (Case study 4).

Vulnerability mapping exercises and monitoring and evaluation activities that have explicit requirements for disaggregated data cost more. Tracking the participation of people who may be vulnerable in programmes is complex. Some people may be hidden from view. It would be helpful if funders identified specific funding.

Mapping groups who may be vulnerable requires data. This takes time and resources, which are both limited in disease outbreaks. Identifying individuals and households is especially time-consuming. Working quickly at scale with limited data may lack precision but delays may cost lives. Speeding up the data collection process helps vulnerable people to be included sooner.

Some quantitative and/or qualitative data may be readily available that supports the identification of groups that may be vulnerable due to widely accepted vulnerability criteria, for example, due to age and/or gender. Sources of such data include government agencies, UN agencies, WHO, NGOs, community groups, medical centres, humanitarian data providers and satellite imagery (see Box 2 for examples). This not only saves resources, but also limits the risk of respondents experiencing participation fatigue.

It is recommended that data is cross-checked against three different sources (triangulation). Ensure that the methodology, stakeholders and results meet your needs before using other people’s data.

Research conducted after the Ebola virus disease outbreak in Liberia suggests that census and household survey data could have been used to relatively quickly map the location of households and populations considered to be socially vulnerable to the disease (in this instance, using poverty as a proxy for vulnerability).

Such an approach could be used in the context of other infectious diseases, but its limitations should be recognised. Quantitative indicators and widely accepted vulnerability criteria are helpful in that they make vulnerability measurable and identifiable. However, they do not capture changes to vulnerability over time; how vulnerability is perceived by individuals and communities; or vulnerabilities that may be context-specific.

Such mapping can be a helpful first-step in planning where and how to allocate resources. A more detailed analysis is required within the highlighted geographical areas to inform programme design (see 4. Imperative: Collaborate with local government and local organisations to identify groups who may be vulnerable; and 5. Your community can help: Engage with the community to identify who may be vulnerable, or who may perceive themselves to be vulnerable).

When starting a project, you should not assume vulnerable groups are neglected. Gathering information about existing organisations and programmes can save time, maximise resources, provide data and support local action after the project has finished.

Collaboration with local governments and local organisations that represent marginalised groups (Rights Holding Organisations, RHOs) can facilitate the identification of people who may be vulnerable within the community. For example, in the context of COVID-19, working with child safeguarding groups, Organisations of People with Disabilities (OPDs), Old People’s Associations (OPAs) and women’s groups.

The evaluation of HBCC interventions for people with disability, older people, and caregivers in Bangladesh, Kenya, Indonesia, Sierra Leone and Zambia concluded that collaborating with government and non-governmental organizations in designing and implementing activities helps to promote inclusive programmes, but noted that such participation needs to be meaningful with strong engagement in the programme, working as partners. This can be supported by, for example, allocating funding for collaborative programme involvement as many such organisations are already overburdened and underfunded. Including them in training can build partnerships. Water for Women’s guidance on effective collaboration between WASH sector organisations and RHOs provides further practical recommendations (see image 5).

Who to approach will vary depending on context. One INGO found that in Nepal, the National Government was active in collating data on groups who may be vulnerable; whereas in Myanmar, religious and community leaders were the key persons to work with.

The earlier the engagement is started, the better. For example, one INGO “tried to involve [the representative groups in HBCC projects] … when we started designing materials, and also asking them if they could set-up focus group discussions to try to access particular members who are part of their society” (INGO).

Such engagement to map where people who may be vulnerable can be resource intensive. Working with others may even slow down progress initially as teams are formed. For example, it will “[extend the] consultation period … before you actually start doing fieldwork … spending longer deciding how we were going to do things” (INGO). Yet such an investment can result in better outcomes when fighting pandemics and better health for everyone longer-term due to sustainable improvements in hygiene practice. Ideally, funders will identify specific funding for such vulnerability mapping exercises (see 2. Engage funders and funding: specify, fund and monitor inclusion).

External mappings of a community will not paint a full picture. Communities are well-placed to determine who may be vulnerable, who is at risk of becoming vulnerable, and who may perceive themselves as being vulnerable (which may be defined differently to how it is defined by others).

Community engagement should therefore feature in all strategies to identify who may be vulnerable or who may perceive themselves to be vulnerable. Engagement should be guided by standards such as UNICEF’s Minimum Standards for Community Engagement to ensure that fundamental principles including Do No Harm (Box 3) are embedded throughout all community engagement activities.

Where vulnerability criteria exist, engagement with the community should include people who may be vulnerable according to the vulnerability criteria with all efforts made to ensure that participation is not tokenistic. For example, in the context of COVID-19, working directly with people who are the poorest in communities instead of relying on the community to identify them.

Standards 1 (Participation), 3 (Inclusion) and 7 (Informed design) of UNICEF’s Minimum Standards for Community Engagement suggest using vulnerability mapping exercises to identify under-represented, disadvantaged, vulnerable and marginalised groups in communities. Organisations will likely have in-house vulnerability assessments, but guidance does exist for those wishing to review what is currently being used, including Tearfund: Beneficiary selection during COVID-19.

Whose reality counts? Listen and learn from multiple sources

Data should be collected (from multiple sources including existing resources; local government and local organisations; and the local community). Determining the selection criteria – and the assistance to be provided – should also be done in consultation with partners and community members (again, consider doing this remotely). It then needs to be clearly communicated. The criteria can then be used to identify and engage directly with the people selected, for example, by self-selection, use of a survey, or by working with existing systems such as health centres and schools, who know the local community.

Funders should identify specific funding for such vulnerability mapping exercises (see lesson 2. Engage funders and funding: specify, fund and monitor inclusion).

It is also worth noting that vulnerability assessments may not translate into action, as “even when the partner/facilitators know who the most vulnerable households in a community are, it doesn’t mean that they can reach them, due to the limited capacity of the partner, or even permission to reach all households” (INGO).

Vulnerability mapping is not a one-time exercise: “vulnerability markers are likely to change through a COVID-19 response – for example, as vaccines became available, those who chose not to be vaccinated, regardless of any other vulnerability criteria, were more vulnerable” (INGO). It is therefore important to continue to identify – and engage with – groups who may be vulnerable throughout the planning, assessment, design, implementation, and monitoring and evaluation stages of programmes.

To do so, keep contact details of all communities, organisations (for example OPDs and OPAs) and individuals spoken to up to date, and ensure feedback mechanisms are in place for any suggestions to affected communities selection criteria to be made.

This Learning Brief is based on limited information and initial experiences of the COVID -19 response. There are more lessons to be learnt. Some will be general, and some may be specific to the context. All the previous lessons in this learning brief can be improved through your experience.

Reflecting on lessons learned using, for example, after action reviews and debrief exercises, helps to embed inclusivity in organisational culture. Training sessions can be used at the end of a project to make sure that new knowledge is not lost.

One INGO commented that “One of the things that came up as an area where we did not address very well [in HBCC-1] in the final learning workshop was inclusivity … so that really put a little bit of thought process going in our country offices and ourselves also, to make sure that in the next iteration we do well when it comes to inclusivity” (INGO).

The same INGO has since worked with country offices to review HBCC-2 projects, looking specifically at what stage addressing inclusivity was considered; whether consultations with groups who may be vulnerable were held; if they were, what were the success stories of doing so; and what were the challenges.

This process found that in HBCC-2 projects, inclusivity was considered by all country offices from planning through to evaluation which resulted in a number of success stories (Case Study 7).

This learning brief was written by Claire Rosato-Scott (WASH independent). Valuable inputs were provided by India Hotopf (LSHTM), Jenny Lamb (LSHTM) and Lauren D’Mello-Guyett (LSHTM) who are part of the Hygiene Hub, and Dani Barrington (University of Western Australia). External reviews were also provided by Brian Reed (WASH independent), Sue Cavill (WaterAid), and Juliet Willetts (University of Technology Sydney).

Published on August 25, 2023

The COVID-19 Hygiene Hub is housed at the London School of Hygiene and Tropical Medicine (LSHTM) and developed in partnership with Center for Affordable Water and Sanitation Technology (CAWST) and Wash’Em.

The Hygiene Hub is funded by the Foreign Commonwealth and Development Office (FCDO).

This project was made possible by UK aid from the UK government, however the views expressed do not necessarily reflect the UK government’s official policies.