Measuring behavior can be challenging

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2. Measuring behavior can be challenging! Some behaviors are sensitive or private Many behaviors are composed of sub-behaviors, each of which should be measured People not always consistent as to when and how they perform the behavior Difficulty of accurate recall �Pro-social� bias

4. Another challenge Behavior change requires antecedent conditions. Hygiene behavior change requires facilities (e.g. latrines) or supplies (e.g. soap). ? Measuring hygiene behavior includes measurement of facilities/supplies as well as of the behavior

6. Main types of methodologies for measuring BC Self-report: interview Inference/proxy: spot check/observation of supplies or facilities, knowledge questions, skill demonstration, participatory methods Observation of behavior ? Each has strengths and weaknesses

7. FFP - SAPQ Indicators for hygiene behavior % caregivers demonstrating proper personal hygiene behaviors* % caregivers demonstrating proper food hygiene behaviors* % caregivers demonstrating proper water hygiene behaviors* % caregivers demonstrating proper environmental hygiene behaviors* �but what are the actual behaviors? �but what are the actual behaviors?

8. * The specific behaviors that comprise these indicators are to be defined by the Cooperating Sponsor in their M&E plan and included as a footnote to the IPTT

9. What are the key behaviors? We will cover the behaviors and ways of measuring them. Note that not possible to have a standard set of indicators because the behaviors vary considerably with the context � e.g. water source and availability, soap availability, means of water storage� We will give examples of the variety as we cover each area. Also much debate on measurement methods (methodology)We will cover the behaviors and ways of measuring them. Note that not possible to have a standard set of indicators because the behaviors vary considerably with the context � e.g. water source and availability, soap availability, means of water storage� We will give examples of the variety as we cover each area. Also much debate on measurement methods (methodology)

10. Why these behaviors?F-Diagram

12. HANDWASHING***

13. What is hand washing? Sub-behaviors: Use running water Use cleansing agent (soap, ash) Lather / rub hands�20 seconds 5 Critical times: AFTER (risk of contact with fecal matter) defecation cleaning a child BEFORE (food handling) food preparation feeding someone eating

16. HW: Self Report Indicator: % washing their hands with soap at least [x] of the appropriate times during a 24 hour recall period Do you have soap in the house? Did you use soap today or yesterday? What did you use it for? (Probe for specifics) �Anything else? (see handout)

17. HW Inference / proxy measure: Spot check Pump, tap seen in house Stored or running water near latrine Cleansing agent near HW stations

18. HW Inference / proxy measure: Skill demonstration Running water used Soap used Hands rubbed / lather obtained [for 20 seconds] Indicator: % who washed hands correctly (met all criteria)

19. HW Structured Observation Observe if hand washing actually happens By caretakers and family members At critical times Using standardized recording instrument During a standard period of time

20. Observation Indicators % of caregivers observed to wash hands with soap �after using the toilet �after cleaning child who has defecated �before preparing food �before feeding child �before eating % of caregivers observed to wash hands with soap at any of the critical times % caregivers observed to have washed with soap at 2+ critical times

21. Pros and Cons of Each Method

22. Observation had been considered the �gold standard� but� In addition to implementation difficulties (intrusive, time consuming and expensive, difficult to train)� Low reliability: Repeat observations yield different results on different days HW decreases each consecutive day of observation

23. Can get different results depending on methodology but the difference may not be great Biran et al study: high degree of correspondence between self report and spot check and possibly behavior

24. Bill Gates will give us the answer! Gates-funded studies: How reactive is a subject with respect to HW behavior, when observed during an extended observation? What is the optimum duration of a structured observation for the purposes of measuring HW behavior? Does hand contamination measured at random times predict hand contamination at times critical to pathogen transmission? What is the association between the presence of improved sanitation facilities and home hygiene?

25. Use the same indicators each time you measure Even if an indicator/method gives you some degree of overestimation or underestimation, if you use the same ones over time, you will still have a good measure of the amount of change.

26. TREATMENT AND STORAGE OF DRINKING WATER***

27. Challenges of Water Treatment & Safe Storage New and complex behavior Separate out drinking water Not current practice Lack of �spare� vessels Choose method/obtain Disinfect Protect

28. Types of water treatment Filtration (various types) Chlorination Boiling Solar disinfection

29. Measuring water treatment Chlorine residual testing (chemical testing) Is there a filter in the house? (spot check) Are solar disinfection bottles on the roof? (spot check) Where do they keep the boiled water (self report + spot check)

30. Indicator: treatment of drinking water % of households practicing effective drinking water treatment What is the main source of drinking water for members of your household? Do you treat your water in any way to make it safer to drink? What do you usually do to make the water safer to drink? (See handout)

31. Water storage containers should have� Narrow neck Hard covers, caps Spigot

32. Indicator: storage of drinking water % of households correctly storing drinking water How do you store drinking water? [If in containers] May I see the containers? Observe characteristics of container. Observe if container covered. (See handout)

33. SANITATION***

35. Improved and Unimproved facility according to MDGs Improved Flush or pour flush to piped sewer system, septic tank, pit latrine Ventilated improved pit latrine Composting toilet Unimproved Flush or pour-flush to street, yard or plot Open pit � without slab Bucket Bush

36. Measuring sanitation improvement A sanitation program will have to decide if it is enough to move up the ladder, or if it wants to attain a certain percentage of households having an improved facility.

37. Sometimes there is a sanitation facility but� It is not hygienic (has feces on floor or wall, has many flies, poorly ventilated) Children do not use it / caregiver does not dispose child�s feces there It is used very little by anyone

38. Sanitation: self report and spot check Please show me where you go to defecate. Observe: Is stool visible on the slab, floor, or walls? Is this toilet shared with any other household? Is water available for handwashing in/near the toilet structure? Please show me where [child] usually defecates. [If child does not defecate in toilet] Where are the child�s feces usually disposed? (See handout) Hygienic sanitation facilityHygienic sanitation facility

39. Wrapping up: hygiene behaviors Few standard indicators because there is a wide range of behaviors Require facilities/supplies to carry out Difficult to measure accurately, but often some simple indicators can give you an acceptable estimate for your needs.

40. Summary of process for PMP Define the specific behaviors and sub-behaviors you are promoting in your setting and program. Measure facilities/supplies as well as the behavior. Select indicators and methodologies that are feasible for your organization to use. This usually means well-crafted survey questions with spot checks incorporated into the instrument.

41. To ease your mind: If you use the same indicators over time, you should get an adequate measure of the amount of change � which tells you whether your activities are effective� and that is probably what you are most interested in.

44. Setting targets How long does it take to change behavior? What targets should be set? What amount of behavior change should we expect?

45. It depends. (sorry) Relative advantage Complexity, skills Norms: Do you think other people are doing it? Do you think others expect you to do it? Compatibility with existing beliefs and values Observability of positive results - preventive behaviors difficult to instill; distal results not as motivating as proximal Affordability/accessibility of resources, supplies Intensity of your intervention