Monitoring water, sanitation, and hygiene programs in cholera outbreaks is critical to improve humanitarian response. The objective of this research was to evaluate, and improve, WASH in cholera monitoring tools currently used in northeast Nigeria. We collected 723 forms from 2019 from three form types, combined them into one database of 980 activities, and stratified data by form type, response, implementing organization, activity, month/day, and geographical area. We conducted seven key informant interviews (KIIs) with monitoring tool users and decision-makers. Data irregularities (including in design, collection, and entry) led to an inability to meaningfully analyze monitoring forms. In KIIs, eight themes emerged: ease of use of current tools, improvement in monitoring over time, lack of access to data, need for training, inconsistent reporting practices, need for modification of current questions, need for the addition of new questions, and connectivity issues. Although informants reported monitoring helped organizations identify gaps during the response, the scarcity and inconsistency of the reported data make it difficult to draw any conclusions about program effectiveness, accountability in humanitarian response, or to make recommendations for improving programming. To improve monitoring, we recommend refining data collection by increasing the quantity of data reported, data consistency, and data relevancy.
Globally, cholera continues to cause morbidity and mortality, and the Global Task Force on Cholera Control (GTFCC) works with countries affected by cholera to develop National Cholera Plans (NCPs). Water, sanitation, and hygiene (WASH) can prevent and/or control cholera. However, WASH program success varies, and is not necessarily replicable across contexts. Thus, guidance needs to be developed to assist countries in appropriately designing WASH programming in NCPs. The objective of this project was to develop guidelines for selecting context-specific WASH for cholera response. For that, a literature review of WASH interventions in cholera was completed, a Working Group was convened to collaboratively develop the guidelines, and we conducted key informant interviews (KII) with Working Group experts, representing international and national non-governmental organizations, donors, international organizations and health authorities. Inductive qualitative content analysis of KIIs was completed. KIIs were conducted with 18 informants, and data was coded into 26 subcategories, categorized under: 1) intervention objectives; 2) decision factors; 3) intervention circumstances; 4) influencing factors; and, 5) WASH activities. Based on these categories, we developed guidelines with the following steps: 1) define the disease objective (control, prevention, or elimination); 2) understand and define the broad context (including existing WASH infrastructure and population habits, available funding, outbreak sources and transmission pathways, stakeholder capacity, and access difficulties); and, 3) focus on monitoring of activities, multi-sectoral coordination (including WASH and health), and targeted approaches, both for implementation and future research. Overall, while building upon previous research and guidance, our results expand to include specific guidance for countries incorporating WASH into their NCPs, and highlight the necessity of a broad contextual understanding to select the most appropriate and successful WASH for cholera programming. These results have been used, with GTFCC, to develop a guidance document for including context-specific WASH in NCPs.
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