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.

A health worker washing their hands at a basin in a facility

What the scales measure

The scales ask about people's lived experiences with accessing and using WASH services at health care facilities. They cover six domains (water, sanitation, hygiene, environmental cleaning, waste management, and menstrual health) across four components: availability, accessibility, usability and sufficiency, and reliability over time. Items are written in plain language and ask about experiences over a defined recall period.

How to read the wheel

Six domains, four components

The inner circle holds the six WASH domains. The ring around it holds the four components of WASH security that the scales ask about in every domain.

Hover over, tap, or tab to any part of the wheel to see what it means.

Three perspectives

Patients, clinical staff, and cleaning staff 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 rather than from the facility as a whole, the data support the examination of disparities between these groups, and by other characteristics such as gender and disability status.

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.

Design process

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.

  1. Item 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.

  2. Survey 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.

  3. Validation

    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.

Who is taking part

  • Patientsaged 18 and older
  • Staffat the facility for at least three months
  • About 10facilities per site

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. Patients are approached only after they have been discharged, so that taking part cannot affect the care they receive.

A member of the study team with a questionnaire interviewing a woman seated beside her on a bench in a facility waiting area

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.

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.

What we are learning

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.