About the project
Centering people’s experiences to assess WASH adequacy
The HCF-WISE Scales are survey tools that capture whether WASH services are reliably accessible, acceptable, and adequate to support patients’ and health care facility staff’s needs. They are designed to be applied alongside conventional supply-focused indicators.
Measurement drives action
Good tools produce data that help to evaluate progress, make disparities visible, and identify barriers to equitable access; that support advocacy; and that help to inform the design and implementation of effective policies and programs. While tools for monitoring household WASH conditions have matured considerably over the past two decades, measures for WASH in institutions have not kept pace.
The indicators that do exist for health care facilities focus primarily on the presence of WASH infrastructure: is there an improved water source on the premises, are there usable toilets, is there hand hygiene at the point of care, is waste segregated. These are necessary but not sufficient for WASH security. They cannot tell whether a service is meeting the needs of the people who rely on it. Water can be available on the premises, for example, but run out before the end of the day, leaving staff to ration it between patients. Without that information, decision-makers are limited in their ability to pinpoint where services are failing and to understand why investments may not produce the intended benefits for patients and staff.
The HCF-WISE project addresses this measurement gap by designing tools that evaluate WASH adequacy for diverse users, comparably across contexts and over time.
What the scales measure
The scales ask about people's lived experiences along several dimensions of service delivery: accessibility, acceptability, perceived adequacy, and reliability. These dimensions draw on the normative criteria of the human rights to water and sanitation, under which services must be available, physically accessible, safe, acceptable, and affordable for everyone. Items are written in plain language and ask about experiences over a defined recall period.
Six domains
Water
Availability, perceived safety, and accessibility of water for drinking, for clinical care, and for cleaning and hygiene at the facility.
Sanitation
Accessibility, privacy, safety, and adequacy of sanitation facilities for the people who need them.
Hygiene
Accessibility and adequacy of hygiene facilities for washing hands as desired.
Environmental cleaning
Adequacy of cleaning in wards, treatment rooms, and other care spaces, and of the supplies and equipment needed to carry it out.
Waste management
Adequacy of waste management for maintaining clean care spaces and reducing the risk of contamination.
Menstrual health
Ability to manage menstrual needs safely, privately, and with dignity while at the health care facility.
Three perspectives
Patients
Adults aged 18 and older.
Clinical staff
Those who provide clinical care or administrative support: physicians, clinical officers, nurses, midwives, and laboratory staff.
Cleaning staff
Those responsible for environmental cleaning, hygiene, and maintenance: cleaners, orderlies, supervisors, and health service technicians.
All three groups are surveyed at every site because they use the same building and often describe it differently. Cleaning and maintenance staff in particular hold operational knowledge about WASH that is rarely captured in existing monitoring frameworks. Because responses are collected from individuals, the data support the examination of disparities between these groups, and by other characteristics such as gender and disability status.
How the study works
The project follows a multi-phase design adapted from the methods behind the Household (HWISE) and Individual (IWISE) Water Insecurity Experiences Scales, which are now validated for use globally, and from published best practice for developing and validating scales.
1Item development
Candidate questions
Candidate survey questions were drawn from a review of existing WASH instruments and from consultation with WASH experts across research, policy, and practice.
2Survey refinement
Cognitive interviews
Cognitive interviews with patients and staff are conducted at every site to assess whether respondents interpret the questions as intended, and to understand how they arrive at their answers. Items are then revised or dropped based on what those interviews show.
3Validation
Surveys paired with facility assessments
Surveys are then administered to several hundred patients and staff per site and paired with a structured assessment of each facility's WASH infrastructure, using observational methods recommended by WHO and UNICEF. This allows direct comparison between experiential WASH insecurity and conventional supply-focused indicators at the same facilities.
Once data from across the consortium are harmonized, psychometric analyses will determine which items perform equivalently across sites and constitute the final scale.
Who takes part
In health care facilities, the study works with patients aged 18 years and older, and with staff who have worked at the facility for at least three months. Staff fall into two groups: those who mainly provide clinical care or administrative support, such as physicians, clinical officers, nurses, midwives, and laboratory and data staff; and those who mainly support environmental cleaning, hygiene, and maintenance, such as cleaners, orderlies, cleaning supervisors, and health service technicians. A typical site spans about ten facilities.
Participation is voluntary and occurs during a single session, held in a private space at the facility – respondents may skip any question they prefer not to answer.
Ethics and data protection
Ethical review
The study is approved by the Institutional Review Board of Northwestern University (STU00219169), and local ethical approval is obtained at every site before data collection begins. Site teams provide documentation of local approval and of participant informed consent.
Data protection
Patients are approached only after they have been discharged, so that taking part cannot affect the care they receive. Survey responses are collected privately by trained study staff on tablets. Names are not stored with responses, data are held on encrypted, password-protected servers, and access is limited to trained study personnel. Results are never reported in a way that could identify an individual.
Returning results to drive change
Every participating site receives short, policy-relevant summary reports of de-identified findings, written for the people who can act on them: participating facilities, local development partners, and government officials.
Part of the WISE Scales family
The HCF-WISE Scales join a family of validated experiential water insecurity measures: the Household Water Insecurity Experiences (HWISE) Scale and the Individual Water Insecurity Experiences (IWISE) Scale. A parallel instrument for schools, the School-WISE Scales, is being developed by the same consortium.