Impact of P.A.C.E. on WASH Behaviors: Program Evaluation in Madhya Pradesh

"[T]he P.A.C.E. program helped respondents adopt correct WASH behaviors and self-efficacy and self-assertive efficacy helped them to sustain the behavior for a period of one year. Their inability to continue correct WASH behaviors may be attributed to many factors, including COVID-19..."

Literature suggests that, while women play a significant role in managing water, sanitation, and hygiene (WASH) at home, social norms do not allow women to participate in WASH decision-making. The Gap Inc.'s Personal Advancement & Career Enhancement (P.A.C.E.) programme intends to build women's knowledge and skill for driving change in WASH behaviours and improving women's involvement in decision-making. The International Center for Research on Women (ICRW) conducted a longitudinal study to assess the adoption and sustainability of WASH behaviours among P.A.C.E. graduates in Madhya Pradesh (MP), India. This report presents the findings from the impact evaluation study.

In 2017, the global apparel retailer Gap Inc. and the United States Agency for International Development (USAID) launched the Women + Water (W+W) Alliance to increase access to safe water supplies and improve sanitation and hygiene practices among women and communities touched by the garment industry. W+W's theory of change (TOC) aims to improve and sustain the health and well-being of women and communities by ensuring that key WASH practices are adopted in the community and that quality resources are available, accessible, and sustainably managed in the communities. On the demand side, the TOC postulates that women who participate in P.A.C.E. training will have enhanced knowledge, life skills, and capacity to champion WASH, which will help them advance their agency, self-efficacy, and decision-making within the household. These factors, in turn, are expected to improve household demand for improved WASH facilities. If successful, this approach could be replicated and scaled up in other countries that are heavily engaged in the global apparel industry.

To achieve this outcome, CARE India undertook P.A.C.E. trainings with women in MP and Maharashtra, India. Learning groups (LGs) with a maximum of 35 women were formed after voluntary enrolment drives were conducted in villages of selected blocks across 5 selected districts of MP and 2 selected districts of Maharashtra. The LGs received weekly sessions, a total of 32 sessions over a period of 6 months, amounting to 48 hours of curriculum. Those who completed 70% of the 4 core modules - Communication, Problem Solving and Decision Making, Time and Stress Management, and WASH - were considered P.A.C.E. graduates. This report presents findings from the evaluation conducted with P.A.C.E. graduates in 3 districts (Sehore, Dhar, and Khandwa) of MP.

Unlike the usual pre-post study design, where the baseline survey is conducted prior to the intervention, the first round of survey in this study was conducted soon after completion of the training (September - December 2019), as the objective was to examine 2 factors: (i) the influence of P.A.C.E. training outcomes on adoption and maintenance of WASH behaviours; and (ii) how women use both WASH knowledge and the life skills that they receive from P.A.C.E. to amplify their voice and take part in decision-making in the household. Conducted in February 2021, the endline was originally planned for one year after baseline (i.e., September 2020) but was delayed by 5 months due to COVID-19 pandemic. The same cohort of women who participated in the baseline were interviewed at the endline.

ICRW stresses that the findings need to be understood in the context of pandemic-related restrictions such as lockdown and social distancing. P.A.C.E. participants did not have the support of the programme team nor of their peers or community members to help them maintain the awareness and practices they may have cultivated during the P.A.C.E. training. Thus, a decline in most of the indicators from baseline to endline was expected, and "no decline" could be interpreted as sustaining the behaviour.

That said, select findings include:

• Access to WASH facilities: Access to improved sources of water reduced from baseline (89%) to endline (85%), as women's access to piped water (piped into dwelling/plot and public tap) declined, and a higher percentage of respondents collected water from unprotected well at endline. A significantly higher proportion of women collected water in one trip at endline compared to baseline, but a higher percentage of women reported collecting water from a source that was more than 500 meters away from home, hence increasing average time to collect water. It was observed that 46% of women reported an increase in the number of trips to collect water because of increase in household size during the pandemic. Also, access to improved toilets and availability of water near the toilet increased significantly at endline, but the percentage of respondents with no access to any toilet facility remained the same at both survey points. The use of sanitary napkins had increased significantly at endline compared to baseline, but only 12% women reported not using the same absorbent during the pandemic due to their inability to go to the store, insufficient money to buy the product, or non-availability of the product.
• WASH attitudes and behaviours: Responsibility for collecting water for daily household needs remains primarily with women. However, the study identified some positive changes in attitudes towards toilet use and maintenance, as reported by women at endline. A significantly higher proportion of women agreed that open defaecation causes diseases. A positive shift in select gender attitudes was observed, as a significantly lesser percentage of respondents agreed that cleaning the toilet is the responsibility of women alone. A significantly lower percentage of respondents reported washing hands after disposing off child faeces, after child defaecates, and before feeding the child. Despite the decline in handwashing, a higher percentage of respondents reported washing hands with soap each time after defaecation, before cooking, and before eating during endline than baseline. At this point, it is important to recall that the availability of piped water reduced significantly, and the average time to collect water increased significantly, which could have impacted the frequency of handwashing.
• Decision making: Women were responsible for making water-related decisions in the household, such as decisions on how much water is required for daily household needs, what will be the main source of drinking water, who will have the responsibility to collect and filter water, and the type of water filter to be used. Fewer women reported making decisions on construction of toilets at endline compared to baseline, and decisions on modification or construction of toilets were also mostly made by men in the household. Apart from making decisions on household-related matters, 46% of women reported they made important decisions of their life on their own. There was also an increase in the percentage of respondents at endline who made the decision to participate in self-help groups (SHGs) and how to spend their own money.
• Women's self perception: While a significant decline was observed in the average self-efficacy and self-assertive efficacy scores at endline, the results indicate that COVID-19 influenced women's self-perception negatively. ("It will be important to further explore the factors that impacted women's self-perception negatively during the pandemic. Was it the presence of male family members or the isolation that most women experienced due to the strict COVID-19 protocols?") The respondents who reported they can handle stress related to COVID-19 had a higher-than-average self-efficacy score, and education was found to have a positive association with both self-efficacy and self-assertive efficacy.
• Awareness and utilisation of WASH financing: Awareness of respondents about different government schemes, such as the total sanitation campaign, and schemes to construct water sources and toilets increased from baseline to endline. Women received information on government schemes from the sarpanch, neighbours or relatives, and P.A.C.E. programme trainers. A significantly higher proportion of women have bank accounts compared to the baseline, but the ease of access to banking services declined - perhaps due to social containment measures taken during the pandemic.
• Factors associated with positive change in key outcome indicators: Education, standard of living, and SHG membership are factors associated with positive change in the self-efficacy and self-assertive efficacy score. It was observed that SHG membership is also positively associated with decision-making (for self) on mobility and health care and decision-making for the household on construction of toilets. Key P.A.C.E. outcomes - self-efficacy and self-assertive efficacy - have positive associations with the sustained ability to make decisions related to water and with sustained handwashing practices, especially after defaecation, before cooking, and before eating.

The evaluation thus implies the need to continue investing in building women's self-efficacy and self-assertive efficacy - both for improving WASH behaviours and for building resilience. P.A.C.E. outcomes can be further strengthened by reinforcing key messages for a sustained period after completion of the P.A.C.E. training. In addition, the LGs formed for P.A.C.E. training can further be leveraged for improving both the P.A.C.E. key outcomes and WASH outcomes like self-efficacy, self-assertive efficacy, participation of women in household decision making, and adoption of correct handwashing practice. While the P.A.C.E. programme equips women with information and skills to negotiate the gender dynamics within the household, there is a need to shift the gender power relations both at the household and community levels.