How are hygiene programmes designed in crises? Qualitative interviews with humanitarians in the Democratic Republic of the Congo and Iraq

Abstract

Background Hygiene behaviour change programmes are complex to design. These challenges are heightened during crises when humanitarian responders are under pressure to implement programmes rapidly despite having limited information about the local situation, behaviours and opinions—all of which may also be rapidly evolving. Methods We conducted in-depth interviews with 36 humanitarian staff involved in hygiene programme design in two crisis-affected settings—one a conflict affected setting (Iraq) and the other amid a cholera outbreak (Democratic Republic of the Congo). Interviews explored decision-making in each phase of the humanitarian project cycle and were thematically analysed. Results Participants considered the design and implementation of hygiene programmes in crises to be sub-optimal. Humanitarians faced sector-specific challenges as well as more general constraints associated with operating within the humanitarian system. Programme-design decisions were made naturalistically and relied heavily on the intuitions and assumptions of senior staff. National organisations were often side-lined from programme design processes despite being in a better position to gather situational data. Consequently, programme design and decision-making processes adopted by humanitarians were similar across the two settings studied and led to similar types of hygiene promotion activities being delivered. Conclusion Hygiene programming in crises-affected settings could be strengthened by initiatives targeted at supporting humanitarian staff during the pre-implementation programme design phase. This may include rapid assessment tools to better understand behavioural determinants in crisis-affected contexts; the use of a theory of change to inform the selection of programme activities; and funding mechanisms which encourage equitable partnerships, phased programming, regular adaptation and have programmatic components targeted at sustainability and sector capacity building. Initiatives aimed at sector reform should be cognisant of inter and intra-organisational dynamics, the ways that expertise is created and valued by the sector, and humanitarian habits and norms that arise in response to system constraints and pressures. These micro-organisational processes affect macro-level outcomes related to programme quality and acceptability and determine or limit the roles of national actors in programme design processes.

Using Wash’Em to design handwashing programmes for crisis-affected populations in Zimbabwe: A Process Evaluation

“…Prior research on hygiene programme design in these settings [12][13][14] has indicated that implementers often have to compromise on more 'ideal' processes of programme design due to the perceived imperative to act with urgency and the associated time pressures and stress that come with this. As such programmes tend to rely on the past expertise of managerial staff to make decisions since it is not always possible for organisations to set aside time to learn from communities [14,33,36]. Even when engagement with communities does take place, many programme teams struggle to use this data to contextualise programmes [14].…”

“…As such programmes tend to rely on the past expertise of managerial staff to make decisions since it is not always possible for organisations to set aside time to learn from communities [14,33,36]. Even when engagement with communities does take place, many programme teams struggle to use this data to contextualise programmes [14]. However, when community engagement is done well and when learning feeds back into programme implementation, research indicates that programmes are more accepted, relevant, trusted and likely to lead to positive outcomes [37][38][39][40].…”

“…Wash'Em provides a semi-structured way for humanitarians, with limited experience in qualitative methods, to engage with communities and immediately use the results to influence programme design. As the name suggests, the Rapid Assessment Tools are not intended to be as 'deep' as traditional anthropological methods but may serve as a useful way of starting to strengthen qualitative capacities in the sector, something that has been acknowledged as weakness in past responses [14,47,48].…”

“…The process of implementing Wash'Em may have also seemed burdensome to implementers in Zimbabwe because budgets were so limited. It is not unusual for humanitarian organisations to be working with limited budgets for hygiene programming and this has been recognised as a chronic challenge in the sector [14,19,49,50]. The Zimbabwean team decided to prioritise the limited funds they had for handwashing infrastructure.…”

“…Each activity comes with a step-bystep guide to aid organisations in planning the logistics and delivery of their programme. The Wash'Em process was designed based on several years of research and iterative improvements based on feedback from humanitarian actors [14,17,18]. It can be completed in as little as two days [19] and has already been used in more than 94 humanitarian responses since March 2020.…”