1. MICS4 Survey Design Workshop Multiple Indicator Cluster Surveys Survey Design Workshop Household Questionnaire: Handwashing

2. MICS4 Survey Design Workshop Rationale Handwashing with water and soap is the most cost effective health intervention to reduce both the incidence of diarrhoea and pneumonia in children under five Handwashing with soap by caretakers reduces the risk of diarrhoea among under-fives by up to 44% (Curtis & Cairncross, 2003) Hand washing with soap by caretakers reduces the risk of Acute Respiratory Infections among children under-five by 23% (Lubby et.al., 2005)

3. MICS4 Survey Design Workshop Measuring behaviour Direct observations –[Hawthorne effect] Observation may trigger correct behaviour Notoriously difficult using household surveys –DHS experience for measuring self reported behaviour: Huge over reporting of self-reported handwashing behavior

4. MICS4 Survey Design Workshop Alternatives to direct observations and self-reporting Measuring knowledge (to name the most important times when people should wash their hands) –Requires extensive probing –Does not equate to, nor reflect behaviour –is not a direct or even a proxy measure of behaviour Measuring a specific place for handwashing with water and soap [MICS Approach] (to monitor the likelihood that handwashing with water and soap takes place)

5. MICS4 Survey Design Workshop Observing the handwashing place Research has found that having soap and water at a specific place which is designated for handwashing is associated with reduced risk of diarrhoeal diseases

6. MICS4 Survey Design Workshop MICS4 Indicators #3.21 - Place for Handwashing The proportion of households with a designated place for handwashing where water and soap are present Rationale: Presence of designated place with water and soap present best matches observed hand- washing behaviour

7. MICS4 Survey Design Workshop MICS4 Indicators # 3.22 - Availability of Soap The proportion of households with soap anywhere in the dwelling Rationale: Measure of market access to soap (bar, liquid, powder) Some degree of awareness about benefits of soap

8. MICS4 Survey Design Workshop Process of formulating HW questions Extensive group consultations: PPP (Public Private Partnership) on Handwashing –Worldbank, USAID (AED-HIP), LSHTM, CDC-Atlanta, Univ. of NY – Buffalo, UNICEF (WASH, SMS) UNICEF-MICS, ORC-Macro (DHS) Validation: Research by various partners

9. MICS4 Survey Design Workshop Questions HW1. Please show me where members of your household most often wash their hands. –Observed –Not observed Not in dwelling /yard /plot No permission to see Other reason

10. MICS4 Survey Design Workshop Questions Observations only! HW2. Observe presence of water at the specific place for handwashing. HW3. Record if soap or detergent is present at the specific place for handwashing.

11. Questions If soap or detergent is not present at the specific place for handwashing –HW4 and HW5 asking to see soap, detergent or any other locally used cleansing agent used for washing hands MICS4 Survey Design Workshop

12. Special cases In countries where local cleansing agents are widely used for handwashing: –Local cleansing agents (ash, mud, sand) equate to soap –Requires adjusting the questions and response categories (HW3-5) to include …….soap or local cleansing agent……

13. MICS4 Survey Design Workshop Concerns Questions dont measure actual behaviour Irrelevant to many urban settings and middle income countries where there is a high water and sanitation coverage Observations take time Showing of soap may take time Presence of tap requires verification of water availability (open the tap to see..)

14. MICS4 Survey Design Workshop Background documentation See MICS4 Manual MICS4 Explanatory note on handwashing module.doc

15. MICS4 Survey Design Workshop For questions or when in doubt……….. Please contact: 1)MICS-team NYHQ 2)DPP/SMS Monitoring Specialist Water and Sanitation: Rolf Luyendijk: rluyendijk@unicef.org