The determinants of handwashing behaviour in domestic settings: An integrative systematic review

A cross-sectional survey assessing the influence of theoretically informed behavioural factors on hand hygiene across seven countries during the COVID-19 pandemic

BACKGROUND

Human hygiene behaviours influence the transmission of infectious diseases. Changing maladaptive hygiene habits has the potential to improve public health. Parents and teachers can play an important role in disinfecting surface areas and in helping children develop healthful handwashing habits. The current study aims to inform a future intervention that will help parents and teachers take up this role using a theoretically and empirically informed behaviour change model called the Capabilities-Opportunities-Motivations-Behaviour (COM-B) model.

METHODS

A cross-sectional online survey was designed to measure participants' capabilities, opportunities, and motivations to [1] increase their children's handwashing with soap and [2] increase their cleaning of surface areas. Additional items captured how often participants believed their children washed their hands. The final survey was administered early in the coronavirus pandemic (May and June 2020) to 3975 participants from Australia, China, India, Indonesia, Saudi Arabia, South Africa, and the United Kingdom. Participants self-identified as mums, dads, or teachers of children 5 to 10 years old. ANOVAs analyses were used to compare participant capabilities, opportunities, and motivations across countries for handwashing and surface disinfecting. Multiple regressions analyses were conducted for each country to assess the predictive relationship between the COM-B components and children's handwashing.

RESULTS

The ANOVA analyses revealed that India had the lowest levels of capability, opportunity, and motivation, for both hand hygiene and surface cleaning. The regression analyses revealed that for Australia, Indonesia, and South Africa, the capability component was the only significant predictor of children's handwashing. For India, capability and opportunity were significant. For the United Kingdom, capability and motivation were significant. Lastly, for Saudi Arabia all components were significant.

CONCLUSIONS

The discussion explores how the Behaviour Change Wheel methodology could be used to guide further intervention development with community stakeholders in each country. Of the countries assessed, India offers the greatest room for improvement, and behaviour change techniques that influence people's capability and opportunities should be prioritised there.

Systemic absorption of benzalkonium chloride after maximal use of a consumer antiseptic wash product

An in vivo pharmacokinetic study was conducted using consumer antiseptic wash containing 0.13% benzalkonium chloride (BAC) to assess the effect of dermal absorption on long-term systemic exposure to BAC. The objective of the study was to determine blood levels of BAC under maximal use conditions. Subjects were enlisted to wash their hands 60 s with soap containing 0.13% BAC 30 times per day over an 8-9 h time period for 5 consecutive days. The test product with the highest absorption potential was selected based on market share and results from in vitro permeation testing. Blood plasma was collected from subjects on 32 occasions over the 6-day study period. Plasma samples were analyzed for the C₁₂ and C₁₄ homologs of BAC using LC-MS/MS with a lower limit of quantitation (LLOQ) of 106.9 and 32.6 ng/L, respectively. For the 32 subjects, C₁₂ homolog was detected above the LLOQ in only four of 1,024 plasma samples at 117.8-191.7 ng/L, and C₁₄ homolog was detected in only one sample at 59.5 ng/L. Consequently, systemic exposure to BAC in antimicrobial soap is very low and below the level of concern identified by the U.S. Food and Drug Administration (500 ng/L) even under maximal use conditions.

Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study

Background

Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility –based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants.

Methods

This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours.

Results

Birth attendants’ compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants’ qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives’ hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception.

Conclusion

The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants’ hand hygiene compliance in our study settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03901-7.

Effectiveness of behaviour change techniques used in hand hygiene interventions targeting older children - A systematic review

BACKGROUND

Promoting good hand hygiene in older children is an important measure to reduce the burden of common diseases such as diarrhoea and acute respiratory infections. The evidence around what works to change this behaviour, however, is unclear.

OBJECTIVES

To aid future intervention design and effective use of resources, this review aims to identify the individual components used in hand hygiene interventions and assesses their contribution to intended behavioural change.

METHODS

We systematically searched seven databases for experimental studies evaluating hand hygiene interventions targeting children (age 5-12) and quantitively reporting hand hygiene behaviour. Interventions in each study were categorised as 'promising', or 'non-promising' according to whether they led to a positive change in the targeted behaviour. Behaviour change techniques (BCTs) were identified across interventions using a standard taxonomy and a novel promise ratio calculated for each (the ratio of promising to non-promising interventions featuring the BCT). 'Promising' BCTs were those with a promise ratio of ≥2. BCTs were ranked from most to least promising.

RESULTS

Our final analysis included 19 studies reporting 22 interventions across which 32 unique BCTs were identified. The most frequently used were 'demonstration of the behaviour', 'instruction on how to perform the behaviour' and 'adding objects to the environment'. Eight BCTs had a promise ratio of ≥2 and the five most promising were 'demonstration of the behaviour', 'information about social and environmental consequences', 'salience of consequences', 'adding objects to the environment', and 'instruction on how to perform the behaviour'.

CONCLUSIONS

Our findings suggest that hand hygiene interventions targeting older children should employ a combination of promising BCTs that ensure children understand the behaviour and the consequences of their hand hygiene habits, appropriate hardware is available, and social support is provided. Researchers are encouraged to consistently and transparently describe evaluated interventions to allow promising components to be identified and replicated.

An exploratory pilot study of the effect of modified hygiene kits on handwashing with soap among internally displaced persons in Ethiopia

Background

Internally displaced persons fleeing their homes due to conflict and drought are particularly at risk of morbidity and mortality from diarrhoeal diseases. Regular handwashing with soap (HWWS) could substantially reduce the risk of these infections, but the behaviour is challenging to practice while living in resource-poor, informal settlements. To mitigate these challenges, humanitarian aid organisations distribute hygiene kits, including soap and handwashing infrastructure. Our study aimed to assess the effect of modified hygiene kits on handwashing behaviours among internally displaced persons in Moyale, Ethiopia.

Methods

The pilot study evaluated three interventions: providing liquid soap; scented soap bar; and the inclusion of a mirror in addition to the standard hygiene kit. The hygiene kits were distributed to four study arms. Three of the arms received one of the interventions in addition to the standard hygiene kit. Three to six weeks after distribution the change in behaviour and perceptions of the interventions were assessed through structured observations, surveys and focus group discussions.

Results

HWWS was rare at critical times for all study arms. In the liquid soap arm, HWWS was observed for only 20% of critical times. This result was not indicated significantly different from the control arm which had a prevalence of 17% (p-value = 0.348). In the mirror and scented soap bar intervention arms, HWWS prevalence was 11 and 10%, respectively. This was indicated to be significantly different from the control arm. Participants in the focus group discussions indicated that liquid soap, scented soap bar and the mirror made handwashing more desirable. In contrast, participants did not consider the soap bar normally distributed in hygiene kits as nice to use.

Conclusion

We found no evidence of an increased prevalence of handwashing with soap following distribution of the three modified hygiene kits. However, our study indicates the value in better understanding hygiene product preferences as this may contribute to increased acceptability and use among crisis-affected populations. The challenges of doing research in a conflict-affected region had considerable implications on this study’s design and implementation.

Trial registration

The trial was registered at www.ClinicalTrials.gov 6 September 2019 (reg no: NCT04078633).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00368-3.

SARS-CoV-2: sewage surveillance as an early warning system and challenges in developing countries

Transmission of novel coronavirus (SARS-CoV-2) in humans happens either through airway exposure to respiratory droplets from an infected patient or by touching the virus contaminated surface or objects (fomites). Presence of SARS-CoV-2 in human feces and its passage to sewage system is an emerging concern for public health. Pieces of evidence of the occurrence of viral RNA in feces and municipal wastewater (sewage) systems have not only warned reinforcing the treatment facilities but also suggest that these systems can be monitored to get epidemiological data for checking trend of COVID-19 infection in the community. This review summarizes the occurrence and persistence of novel coronavirus in sewage with an emphasis on the possible water environment contamination. Monitoring of novel coronavirus (SARS-CoV-2) via sewage-based epidemiology could deliver promising information regarding rate of infection providing a valid and complementary tool for tracking and diagnosing COVID-19 across communities. Tracking the sewage systems could act as an early warning tool for alerting the public health authorities for necessary actions. Given the impracticality of testing every citizen with limited diagnostic resources, it is imperative that sewage-based epidemiology can be tested as an early warning system. The need for the development of robust sampling strategies and subsequent detection methodologies and challenges for developing countries are also discussed.

Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

BACKGROUND

Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum.

METHODS

Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours.

RESULTS

Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge.

CONCLUSIONS

Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.

Worry much? Preventive health behaviours related to worry across countries amid COVID-19

This study examined the relationship between worry and health behaviours using an online survey of 69,033 respondents from 32 countries. We hypothesized that past health behaviours predicted worry experienced, which in turn predicted future health behaviours, and included a metric of cultural distance from the US. Past behaviours such as maintaining physical distance predicted higher worry, whereas worry reduced the likelihood of going outside. Being culturally dissimilar to the US was associated with lower worry. However, cultural distance was not associated with future health behaviours. We analyse worry as an approach-avoidance motivator of health behaviours from a cross-cultural perspective, to facilitate effective health communication strategies.

Availability and factors influencing community level handwashing facility in Ethiopia: Implication for prevention of infectious diseases

Background

Handwashing is one of the most effective ways to prevent transmission of infectious diseases. A substantial body of research has examined the status and determinants of handwashing facilities in healthcare settings and schools. However, its status at home in the community, especially in developing countries, remains unclear. This study aimed to examine the availability and factors influencing basic handwashing facilities at households in Ethiopia.

Method

We analysed the 2016 Ethiopian Demographic and Health Survey (EDHS) data. EDHS employed a two-stage stratified cluster sampling technique. Data were collected from the lowest administrative unit (kebele). A multivariable logistic regression model that allowed cluster-level random effects was employed to examine factors that affect the availability of basic handwashing facilities (water plus soap) at households. Estimates from the regression model are reported as odds ratios (ORs) with standard errors clustered at the DHS cluster level to account for a sampling methodology.

Results

In our sample, only 1292 (8% [95% CI, 7.6%–8.4%]) of the households had basic handwashing facilities. Compared with head of household who had no formal education, the odds of having basic handwashing facilities was higher among head of household who completed secondary level of education (adjusted odds ratio [AOR] = 1.83; 95% CI: 1.35–2.49) and higher level of education (AOR = 2.35; 95% CI: 1.63–3.39). Odds of having basic handwashing facilities was increased with having radio (AOR = 1.32; 95% CI: 1.10–1.63) and television (AOR = 1.49; 95% CI: 1.10–2.02) at home. Households that had improved latrine were two times more likely to have basic handwashing facilities (AOR = 2.09; 95% CI: 1.56–2.80). Being at higher household wealth quintiles was associated with increased odds of having basic handwashing facilities.

Conclusion

Very low basic handwashing facilities was demonstrated by this study, whereas, awareness and socio-economic related factors were identified as a determinants for its availability in the household. Greater efforts are needed to increase the coverage of community-level handwashing facilities.

Use of Technology to Access Health Information/Services and Subsequent Association With WASH (Water Access, Sanitation, and Hygiene) Knowledge and Behaviors Among Women With Children Under 2 Years of Age in Indonesia: Cross-sectional Study

BACKGROUND

Water access, sanitation, and hygiene (WASH) remain a public health concern in Indonesia. Proper WASH practices can decrease risk of stunting, wasting, and disease in children under the age of 2.

OBJECTIVE

The purpose of our study is to examine if using technology to access health information and services among Indonesian women affects knowledge and behaviors regarding handwashing and defecation practices.

METHODS

Our study is an interview-based cross-sectional survey. Participants included 1734 mothers of children under 2 years of age. These women were randomly selected and interviewed as part of a 3-stage cluster sampling technique. Our study uses data regarding WASH knowledge which includes benefits of handwashing with soap, 5 critical times of handwashing, risks of open defecation, media of disease transmission, defecation locations, and risks of open defecation. Data regarding WASH behaviors were also included: handwashing with soap, type of latrine used at home, and where defecation took place. This investigation used adjusted and unadjusted logistic and linear regression models to determine differences in WASH outcomes between those who use technology to access health information and services and those who did not.

RESULTS

One result is that Indonesian women with children under 2 years of age who use technology to access health information and services are more likely to know the advantages of proper handwashing (odds ratio [OR] 2.603, 95% CI 1.666-4.067) and know the 5 critical times of handwashing (OR 1.217, 95% CI 0.969-1.528). Women who use technology to access health information are also more likely to know the risks of open defecation (OR 1.627, 95% CI 1.170-2.264) and use a type of toilet (such as a gooseneck or squat toilet) that limits risk (OR 3.858, 95% CI 2.628-5.665) compared to women who did not use technology to access health information.

CONCLUSIONS

Using technology to access health information and services was associated with an increase in handwashing and defecation knowledge. In the future, promoting mothers of children under 2 years of age to access health information through technology might be used to increase handwashing and defecation knowledge as well as safe defecation practices. However, further research should be done to determine how technology may increase the frequency of recommended handwashing behaviors.

COVID-19: urgent actions, critical reflections and future relevance of 'WaSH': lessons for the current and future pandemics

The COVID-19 pandemic placed hygiene at the centre of disease prevention. Yet, access to the levels of water supply that support good hand hygiene and institutional cleaning, our understanding of hygiene behaviours, and access to soap are deficient in low-, middle- and high-income countries. This paper reviews the role of water, sanitation and hygiene (WaSH) in disease emergence, previous outbreaks, combatting COVID-19 and in preparing for future pandemics. We consider settings where these factors are particularly important and identify key preventive contributions to disease control and gaps in the evidence base. Urgent substantial action is required to remedy deficiencies in WaSH, particularly the provision of reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programmes, underpinned by behavioural science, must be adapted to high-risk populations (such as the elderly and marginalised) and settings (such as healthcare facilities, transport hubs and workplaces). WaSH must be better integrated into preparation plans and with other sectors in prevention efforts. More finance and better use of financing instruments would extend and improve WaSH services. The lessons outlined justify no-regrets investment by government in response to and recovery from the current pandemic; to improve day-to-day lives and as preparedness for future pandemics.

Hygienic Risk Exposures Across Ethnic Groups in Rural Areas of Guangxi, China: Prevalence, Associated Factors, and Perceptions of Policy

BACKGROUND

Controlling hygienic risk exposures (HREs) is important for reducing acute respiratory infection or parasitic infection; however, studies across vulnerable ethnicities are limited. This study aimed to identify the prevalence and associated factors of HREs and perception on HRE policies among ethnic groups in Guangxi, China.

METHODS

A community-based cross-sectional study was conducted in rural areas of Guangxi, China, among Han majority and Zhuang, Yao, Miao, Dong, Mulao, and Maonan minorities. The prevalence of HREs and perceptions concerning the HRE policies were presented using descriptive statistics. Associated factors were analyzed using a logistic regression model, and adjusted prevalence ratios and 95% confidence interval were calculated.

RESULTS

High prevalence of HREs on hand and soil hygiene were found in all ethnicities. Miao minority had the highest prevalence of HREs, particularly in poor hand washing (74.1%), infrequent nail clipping (90.4%), and outdoor soil contact (92.7%), compared with the others. Prevalence of HREs in some ethnic minority groups were significantly different from those in Han majority after adjusted with other significant factors. Village leaders were more aware of existing national and community regulations related to HREs than household heads. Village leaders and household heads of almost all ethnic groups perceived high policy's compliance in their village or household on avoiding fertilizing with farmyard manure.

CONCLUSIONS

HREs were prevalent in all ethnic groups, especially in Miao minority. Ethnicity, one of social determinants, was significantly associated with HREs. Raising awareness at both the village and household levels on HREs is needed for all ethnic groups.

When, how, and how long do adults in Germany self-reportedly wash their hands? Compliance indices based on handwashing frequency, technique, and duration from a cross-sectional representative survey

BACKGROUND

Hand hygiene is an efficacious behaviour to prevent community-associated infections. Estimates of the proportion of populations who wash their hands have indicated limited compliance. While biases of self-report items for hand hygiene, such as the tendency to overestimate one's behaviour, represent a limitation, direct survey questions remain important. This study aims to compare indices of handwashing compliance based on single vs. combined handwashing attributes, i.e., its frequency, technique, and duration.

METHODS

Data of a representative survey on hygiene and infection control by the German Federal Centre for Health Education were analysed. In a cross-sectional, computer-assisted telephone interview design, the resident population in Germany aged 16-85 years was surveyed in 2012. For handwashing, duration, frequency in different situations, and technique (use of soap, washing interdigital spaces, and drying hands) were self-reported. Self-reports were rated as (non-)compliant based on national recommendations and combined into single- and multi-attribute indices. Use of hand disinfectants, recall of handwashing instruction plates in public restrooms, and socio-demographics were also assessed. In total, N = 4483 persons participated (response rate: 49.7%). Data were weighted to compensate for sampling bias and analysed by cross-tabulation and multiple logistic regression. Primarily due to missing data, the analysis was confined to N = 4093 respondents (i.e., 91%).

RESULTS

Among women, the proportion of those who reported to wash hands "almost always" in at least seven of nine situations was 30.8% (men: 20.3%). In contrast, 51% of men reported always using soap, drying hands, and washing interdigital spaces (women: 43.5%; p < 0.001). Compliance based on indices that included "frequency" was higher in women by 5.2% for "frequency + technique" (17.6% vs. 12.4%), and 2.5% for "frequency + duration" (13.1% vs. 10.6%) and "frequency + duration + technique" (8.8% vs. 6.3%; p < 0.02). Socio-demographic differences were most consistent regarding higher compliance among healthcare workers. Finally, especially men recalling handwashing instruction plates in public restrooms had higher compliance than those with no recall, namely, for "frequency + technique" (15.4% vs. 10.6%; OR: 1.9), all three attributes (7.6% vs. 5.3%; OR = 1.7), and "technique" (56.9% vs. 47.7%; OR = 1.6). The highest odds ratio was noted for disinfectant use among men (OR = 2.5; 12.2% vs. 4.9%).

DISCUSSION

While being representative for Germany, limitations include the survey's cross-sectionality, response rate, and the study representing the situation in 2012. Nonetheless, indices based on combined attributes allow better comparison to scarce compliance estimates for Germany based on observation. Socio-demographic differences add to existing evidence, e.g., higher compliance by healthcare workers. Finally, although reverse causation is possible, it is notable that although handwashing instruction plates in public restrooms focus on duration and technique, women recalling them reported higher frequency, and men more often report hand disinfectant use, suggesting possible carry-over effects.

CONCLUSION

Self-reported handwashing compliance assessment may be improved by partitioning the behavioural domain into different attributes and using indices based on combinations of these.

I'll trade you diamonds for toilet paper: Consumer reacting, coping and adapting behaviors in the COVID-19 pandemic

In this research, we document some of the many unusual consumer behavior patterns that came to dominate the early days of the COVID-19 pandemic. We offer insights based on theory to help explain and predict these behaviors and associated outcomes in order to inform future research and marketing practice. Taking an environmentally-imposed constraints point of view, we examine behaviors during each of three phases: reacting (e.g., hoarding and rejecting), coping (e.g. maintaining social connectedness, do-it-yourself behaviors, changing views of brands) and longer-term adapting (e.g. potentially transformative changes in consumption and individual and social identity). We discuss implications for marketing researchers and practice.

How to set up government-led national hygiene communication campaigns to combat COVID-19: a strategic blueprint

While large-scale changes in population behaviour are required to reduce the transmission of the severe acute respiratory syndrome coronavirus 2 virus, the emergency context is not conducive to the sort of careful communications planning that would normally be required to meet such a task. Rapid strategic communications planning in a pandemic by governments is, however, possible and necessary. Steps include setting up a dedicated communications task force, mobilising partners and resources, developing a creative brief and theory of change and overseeing the creation, testing, roll out and revision of content. In this short guide, we argue that a minimum of strategic planning can be undertaken rapidly, and that good use can be made of simple principles of behaviour change, even during pandemics. Our aim here is to provide a blueprint that governments and their partners, especially in low-income settings, can follow to design, coordinate and resource national communications efforts to combat the COVID-19 pandemic immediately and for the longer term.

Distribution of hygiene kits during a cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo: a process evaluation

Background

Cholera remains a leading cause of infectious disease outbreaks globally, and a major public health threat in complex emergencies. Hygiene kits distributed to cholera case-households have previously shown an effect in reducing cholera incidence and are recommended by Médecins Sans Frontières (MSF) for distribution to admitted patients and accompanying household members upon admission to health care facilities (HCFs).

Methods

This process evaluation documented the implementation, participant response and context of hygiene kit distribution by MSF during a 2018 cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo (DRC). The study population comprised key informant interviews with seven MSF staff, 17 staff from other organisations and a random sample of 27 hygiene kit recipients. Structured observations were conducted of hygiene kit demonstrations and health promotion, and programme reports were analysed to triangulate data.

Results and conclusions

Between Week (W) 28-48 of the 2018 cholera outbreak in Kasaï-Oriental, there were 667 suspected cholera cases with a 5% case fatality rate (CFR). Across seven HCFs supported by MSF, 196 patients were admitted with suspected cholera between W43-W47 and hygiene kit were provided to patients upon admission and health promotion at the HCF was conducted to accompanying household contacts 5-6 times per day. Distribution of hygiene kits was limited and only 52% of admitted suspected cholera cases received a hygiene kit. The delay of the overall response, delayed supply and insufficient quantities of hygiene kits available limited the coverage and utility of the hygiene kits, and may have diminished the effectiveness of the intervention. The integration of a WASH intervention for cholera control at the point of patient admission is a growing trend and promising intervention for case-targeted cholera responses. However, the barriers identified in this study warrant consideration in subsequent cholera responses and further research is required to identify ways to improve implementation and delivery of this intervention.

The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq

Background

Diarrhoea is one of the most common causes of mortality and morbidity among populations displaced due to conflict. Handwashing with soap has the potential to halve the burden of diarrhoeal diseases in crisis contexts. This study aimed to identify which determinants drive handwashing behaviour in post-conflict, displacement camps.

Methods

This study was conducted in two camps for internally displaced people in the Kurdistan Region of Iraq. A Barrier Analysis questionnaire was used for assessing the determinants of hand washing behaviour. Participants were screened and classified as either ‘doers’ (those who wash their hands with soap at critical times) or ‘non-doers’ (those who do not wash their hands with soap at critical times). Forty-five doers and non-doers were randomly selected from each camp and asked about behavioural determinants. The Barrier Analysis standard tabulation sheet was used for the analysis.

Results

No differences were observed between doers and non-doers in relation to self-efficacy, action efficacy, the difficulties and benefits of handwashing, and levels of access to soap and water. In the first of the two camps, non-doers found it harder to remember to wash their hands (P = 0.045), had lower perceived vulnerability to diarrhoea (P = 0.037), lower perceived severity of diarrhoea (P = 0.020) and were aware of ‘policies’ which supported handwashing with soap (P = 0.037). In the second camp non-doers had lower perceived vulnerability to diarrhoea (P = 0.017).

Conclusions

In these camp settings handwashing behaviour, and the factors that determine it, was relatively homogenous because of the homogeneity of the settings and the socio-demographics of population. Handwashing programmes should seek to improve the convenience and quality of handwashing facilities, create cues to trigger handwashing behaviour and increase perceived risk. We identify several ways to improve the validity of the Barrier Analysis method such as using it in combination with other more holistic qualitative tools and revising the statistical analysis.