Nongovernmental Organization Practitioners’ Perspectives on the Challenges and Solutions to Changing Handwashing Behavior in Older Children: A Qualitative Study

We explore the challenges to handwashing interventions targeting older children and recommended solutions from nongovernmental organization practitioners’ perspectives involved in the design, coordination, implementation, or evaluation of child-targeted HWWS interventions.


Introduction
Thank you for agreeing to take part in this interview. My name is XX and I am a researcher at the London School of Hygiene and Tropical Medicine. I am conducting a piece of research exploring organisational approaches to handwashing promotion in emergency and development responses and trying to understand the factors behind the decision-making process.
Just to clarify so that we are on the same page, since there can be many different interpretations of the term handwashing promotion, here what I mean by handwashing promotion is any activity designed to increase handwashing with soap. So that includes messaging and education as well as infrastructural improvements such as providing soap and handwashing stations.
[The following questions serve as a guide for discussion but can be flexible so long as the topic of conversation remains on the broader context of handwashing promotion for children. Probes  In what ways has your organisation been involved with commissioning or implementing handwashing promotion for children?

Understanding of determinants
Firstly, before we delve more specifically into the programmes you have implemented, I'd like to ask you to think about children's handwashing more broadly. I'm going to share my screen with youthis is a broad way we think the determinants of handwashing could be categorised.
3. Looking at these, which do you think are the most important determinants of child handwashing?
• Do you think this is any different in emergency settings/outbreak contexts? Now, I will move more specifically to your organisation's approaches.

Intervention selection and design
4. Who is involved in the decision-making around which handwashing promotion programmes for children are implemented by your organisation?
• How much input does the country office have?
• Who makes the final decision?
5. If presented with a selection of handwashing promotion interventions or programmes your organisation could implement, what factors do you consider when choosing which one to implement?
• Is a needs assessment done?
• Is any formative research conducted in order to determine the barriers and enablers to handwashing? For each intervention probe on: • Where was this? Location and context • What age groups were targeted?
• What did this intervention involve: what hardware, software, specific activities?
• What were the key messages and what channels were used for message delivery?
• What was the mechanism of action -how does this intervention lead to a change in behaviour? • Who implemented the intervention?
• What was your organisation's role -implementer/funder? • How long was the intervention and how much was it repeated?
• What was the time scale for delivery? 7. Do you think this/these interventions appropriately address what you feel are the determinants of handwashing behaviour and did they motivate children?
• What are the barriers?
• What should have been different? 16. Thinking about the different approaches you have taken, how feasible/practical have these been to implement in the field? • Were they well understood by field staff and did they find it easy to implement as directed? • Were there any time constraints or anything that made it difficult to implement as directed? • Were they able to reach the right audience? • Were they easy to repeat?