The trajectory of COVID-19 pandemic and handwashing adherence: findings from 14 countries

Potential for Glove Risk Amplification via Direct Physical, Chemical, and Microbiological Contamination

This review focuses on the potential direct physical, chemical, and microbiological contamination from disposable gloves when utilized in food environments, inclusive of the risks posed to food products as well as worker safety. Unrecognized problems endemic to glove manufacturing were magnified during the COVID-19 pandemic due to high demand, increased focus on PPE performance, availability, supply chain instability, and labor shortages. Multiple evidence-based reports of contamination, toxicity, illness, deaths, and related regulatory action linked to contaminated gloves in food and healthcare have highlighted problems indicative of systemic glove industry shortcomings. The glove manufacturing process was diagramed with sources and pathways of contamination identified, indicating weak points with documented occurrences detailed. Numerous unsafe ingredients can introduce chemical contaminants, potentially posing risks to food and to glove users. Microbial hazards present significant challenges to overall glove safety as contaminants appear to be introduced via polluted water sources or flawed glove manufacturing processes, resulting in increased risks within food and healthcare environments. Frank and opportunistic pathogens along with food spoilage organisms can be introduced to foods and wearers. When the sources and pathways of glove-borne contamination were explored, it was found that physical failures play a pivotal role in the release of sweat build-up, liquefaction of chemical residues, and incubation of microbial contaminants from hands and gloves. Thus, with glove physical integrity issues, including punctures in new, unused gloves that can develop into significant rips and tears, not only can direct physical food contamination occur but also chemical and microbiological contamination can find their way into food. Enhanced regulatory requirements for Acceptable Quality Limits of food-grade gloves, and the establishment of appropriate bioburden standards would enhance safety in food applications. Based on the information provided, together with a false sense of security associated with glove use, the unconditional belief in glove chemical and microbiological purity may be unfounded.

Perceived Effectiveness of COVID-19 Preventive Practices and Behavioral Intention: Survey of a Representative Adult Sample in the United States

BACKGROUND

Using existing models of behavioral health promotion, specifically the Extended Parallel Process Model, previous research has identified factors that may impact engagement in preventive health behaviors during the COVID-19 pandemic such as perceived threat, perceived susceptibility to the threat, perceived severity, and perceived efficacy.

OBJECTIVE

This study aims to examine the role of perceived effectiveness of COVID-19 preventive behaviors, perceived susceptibility, perceived threat, and perceived severity of COVID-19 in participants' intentions to engage in Centers for Disease Control (CDC)-recommended individual health behaviors in the first year of the pandemic.

METHODS

In October 2020, a representative sample of 506 US adults completed a web-based survey through the RAND American Life Panel.

RESULTS

The study primarily found that participants who perceived that CDC-recommended health practices were effective had stronger intentions to engage in those practices. The second strongest correlate was participants' perceived severity of COVID-19 across the United States. Perceived effectiveness of recommended practices accounted for the largest variance in behavioral intention. However, analysis of individual behaviors indicated a mismatch in the behaviors perceived to be the most effective (avoiding sick people and mask-wearing) and those participants indicated intention to engage in (throwing away used tissues, avoiding sick people, and coughing into their elbows) in the next 30 days.

CONCLUSIONS

The authors recommend tailoring public health messaging to address the perceived threat of COVID-19 and self-efficacy. Thus, health promotion efforts should emphasize the effectiveness of CDC-recommended practices while highlighting the pandemic's severity. Additionally, rebuilding trust in public health messaging and messengers is necessary to increase perceived self-efficacy. As the COVID-19 pandemic continues, health messaging must continue to promote and build trust in CDC-recommended health practices and educate regarding the efficacy of vaccination and other preventive behaviors.

When do people increase COVID-19 protective behaviors? A longitudinal analysis of the impact of infections among close contacts and in the community

Studies examining individual-level changes in protective behaviors over time in association with community-level infection and self or close-contact infection with SARS-CoV-2 are limited. We analyzed overall and demographic specific week-to-week changes in COVID-19 protective behaviors and their association with COVID-19 infections (regional case counts and self or close contacts). Data were collected through 37 consecutive weekly surveys from 10/17/2021 - 6/26/2022. Our survey panel included 212 individuals living or working in St. Louis City and County, Missouri, U.S.A. Frequency of mask-wearing, handwashing, physical distancing, and avoiding large gatherings was self-reported (more/the same/less than the prior week). Close contact with COVID-19 was reported if the panel member, their household member, or their close contact tested positive, got sick, or was hospitalized for COVID-19 in the prior week. Regional weekly COVID-19 case counts were matched to the closest survey administration date. We used generalized linear mixed models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations. Evidence for effect modification was assessed using the likelihood ratio test. Increased protective behaviors were positively associated with COVID-19 case counts (ORhighest vs. lowest case count category = 4.39, 95% CI 3.35-5.74) and with participant-reported self or close contacts with COVID-19 (OR = 5.10, 95% CI 3.88-6.70). Stronger associations were found for White vs. Black panel members (p <.0001). Individuals modulated their protective behaviors in association with regional COVID-19 case counts and self or close contact infection. Rapid reporting and widespread public awareness of infectious disease rates may help reduce transmission during a pandemic by increasing protective behaviors.

Protective behaviors during COVID-19 confinement measures in Greece: the role of anxiety, perceived risk and risky-choice framing

Confinement measures at the beginning of the COVID-19 pandemic imposed major changes on the global population. The aim of this study was to explore the level to which the public adhered to protective guidelines by adopting the most appropriate behaviors at that time (such as hand washing with soap and using sanitizer gel) and to identify the determinants of these behaviors. A purposive sample of 1013 individuals was invited and voluntarily participated in the online survey. The questionnaire collected information on demographic data, hand washing, risk perception, anxiety (through the S = Anxiety scale of STAI) and risky-choice framing. Results showed increased levels of anxiety, a moderate perception of the risk of catching coronavirus and increased adoption of protective behaviors, such as handwashing and cleaning surfaces with disinfectant/antiseptic products. Multiple ordinal logistic regression models showed that being female, more educated and cleaning home with disinfectant / antiseptic products predicted handwashing with soap. Additionally, having an increased perception of getting the coronavirus, being older and cleaning the home with disinfectant / antiseptic products predicted handwashing with antiseptics. Public health interventions should take into consideration the unified cleaning pattern and the combined effect of sociodemographic variables and risk perception on the adoption of protective behaviour in the context of a health crisis which is out of people's control.

Predictors of changing patterns of adherence to containment measures during the early stage of COVID-19 pandemic: an international longitudinal study

BACKGROUND

Identifying common factors that affect public adherence to COVID-19 containment measures can directly inform the development of official public health communication strategies. The present international longitudinal study aimed to examine whether prosociality, together with other theoretically derived motivating factors (self-efficacy, perceived susceptibility and severity of COVID-19, perceived social support) predict the change in adherence to COVID-19 containment strategies.

METHOD

In wave 1 of data collection, adults from eight geographical regions completed online surveys beginning in April 2020, and wave 2 began in June and ended in September 2020. Hypothesized predictors included prosociality, self-efficacy in following COVID-19 containment measures, perceived susceptibility to COVID-19, perceived severity of COVID-19 and perceived social support. Baseline covariates included age, sex, history of COVID-19 infection and geographical regions. Participants who reported adhering to specific containment measures, including physical distancing, avoidance of non-essential travel and hand hygiene, were classified as adherence. The dependent variable was the category of adherence, which was constructed based on changes in adherence across the survey period and included four categories: non-adherence, less adherence, greater adherence and sustained adherence (which was designated as the reference category).

RESULTS

In total, 2189 adult participants (82% female, 57.2% aged 31-59 years) from East Asia (217 [9.7%]), West Asia (246 [11.2%]), North and South America (131 [6.0%]), Northern Europe (600 [27.4%]), Western Europe (322 [14.7%]), Southern Europe (433 [19.8%]), Eastern Europe (148 [6.8%]) and other regions (96 [4.4%]) were analyzed. Adjusted multinomial logistic regression analyses showed that prosociality, self-efficacy, perceived susceptibility and severity of COVID-19 were significant factors affecting adherence. Participants with greater self-efficacy at wave 1 were less likely to become non-adherence at wave 2 by 26% (adjusted odds ratio [aOR], 0.74; 95% CI, 0.71 to 0.77; P < .001), while those with greater prosociality at wave 1 were less likely to become less adherence at wave 2 by 23% (aOR, 0.77; 95% CI, 0.75 to 0.79; P = .04).

CONCLUSIONS

This study provides evidence that in addition to emphasizing the potential severity of COVID-19 and the potential susceptibility to contact with the virus, fostering self-efficacy in following containment strategies and prosociality appears to be a viable public health education or communication strategy to combat COVID-19.

Knowledge and practice of personal protective measures against COVID-19 in Africa: a systematic review

BACKGROUND

The Coronavirus disease 2019 (COVID-19) pandemic being a newly evolving disease, its response measures largely depend on the practice of and compliance with personal protective measures (PPMs).

OBJECTIVE

This systematic review aimed to examine the knowledge and practice of COVID-19 PPMs in African countries, as documented in the published literature.

METHODS

A systematic search was conducted on Scopus, PubMed, and Web of Science databases using appropriate keywords and predefined eligibility criteria for the selection of relevant studies. Only population-based original research studies (including qualitative, quantitative, and mixed-method studies) done in Africa, and published in the English language were included. The screening process and data extraction were performed according to a pre-registered protocol in PROSPERO (CRD42022355101) and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The quality of included studies was assessed using the Mixed-Method Appraisal Tool. Thematic analysis was used to systematically summarise the studies into four predefined domains: i) knowledge and perception about PPMs, ii) mask use, iii) social/physical distancing, and iv) hand washing/hygiene, including their respective levels and associated factors.

RESULTS

A total of 58 studies across 12 African countries were included, and these were published between 2019 and 2022. African communities, including various population groups, had varying levels of knowledge and practice of COVID-19 PPMs, with lack of personal protective equipment (PPE) (mainly face masks), and side effects (among health care workers) being the major reasons for poor compliance. Lower rates of handwashing/ hygiene were particularly noted in several African countries, especially among the urban poor and slum-dwellers, with the main barrier being the lack of safe and clean water. Various cognitive (knowledge and perception), socio-demographic and economic factors were associated with the practice of COVID-19 PPMs. Moreover, there were evident research inequalities on the regional level, where East Africa contributed 36.2%, West Africa 20.7%, North Africa 17.2%, Southern Africa 6.9%, and no single-country study from Central Africa. Nonetheless, the overall quality of the included studies was generally good, as they satisfied most of the quality assessment criteria.

CONCLUSIONS

There is a need to enhance local capacity to produce and supply PPE. Consideration of various cognitive, demographic and socioeconomic differences, with extra focus on the most vulnerable, is crucial for inclusive and more effective strategies against the pandemic. Moreover, more focus and involvement in community behavioral research are needed to fully understand and address the dynamics of the current pandemic in Africa.

CLINICALTRIAL

The study protocol was registered in PROSPERO (CRD42022355101).

Promoting Hand Hygiene During the COVID-19 Pandemic: Parallel Randomized Trial for the Optimization of the Soapp App

BACKGROUND

Hand hygiene is an effective behavior for preventing the spread of the respiratory disease COVID-19 and was included in public health guidelines worldwide. Behavior change interventions addressing hand hygiene have the potential to support the adherence to public health recommendations and, thereby, prevent the spread of COVID-19. However, randomized trials are largely absent during a pandemic; therefore, there is little knowledge about the most effective strategies to promote hand hygiene during an ongoing pandemic. This study addresses this gap by presenting the results of the optimization phase of a Multiphase Optimization Strategy of Soapp, a smartphone app for promoting hand hygiene in the context of the COVID-19 pandemic.

OBJECTIVE

This study aimed to identify the most effective combination and sequence of 3 theory- and evidence-based intervention modules (habit, motivation, and social norms) for promoting hand hygiene. To this end, 9 versions of Soapp were developed (conditions), and 2 optimization criteria were defined: the condition with the largest increase in hand hygiene at follow-up and condition with the highest engagement, usability, and satisfaction based on quantitative and qualitative analyses.

METHODS

This study was a parallel randomized trial with 9 intervention conditions defined by the combination of 2 intervention modules and their sequence. The trial was conducted from March to August 2021 with interested participants from the Swiss general population (N=232; randomized). Randomization was performed using Qualtrics (Qualtrics International Inc), and blinding was ensured. The duration of the intervention was 34 days. The primary outcome was self-reported hand hygiene at follow-up, which was assessed using an electronic diary. The secondary outcomes were user engagement, usability, and satisfaction assessed at follow-up. Nine participants were further invited to participate in semistructured exit interviews. A set of ANOVAs was performed to test the main hypotheses, whereas a thematic analysis was performed to analyze the qualitative data.

RESULTS

The results showed a significant increase in hand hygiene over time across all conditions. There was no interaction effect between time and intervention condition. Similarly, no between-group differences in engagement, usability, and satisfaction emerged. Seven themes (eg, "variety and timeliness of the task load" and "social interaction") were found in the thematic analysis.

CONCLUSIONS

The effectiveness of Soapp in promoting hand hygiene laid the foundation for the next evaluation phase of the app. More generally, the study supported the value of digital interventions in pandemic contexts. The findings showed no differential effect of intervention conditions involving different combinations and sequences of the habit, motivation, and social norms modules on hand hygiene, engagement, usability, and satisfaction. In the absence of quantitative differences, we relied on the results from the thematic analysis to select the best version of Soapp for the evaluation phase.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04830761; https://clinicaltrials.gov/ct2/show/NCT04830761.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2021-055971.

Handwashing adherence during the COVID-19 pandemic: A longitudinal study based on protection motivation theory

RATIONALE

The associations between the number of COVID-19 cases/deaths and subsequent uptake of protective behaviors may reflect cognitive and behavioral responses to threat-relevant information.

OBJECTIVE

Applying protection motivation theory (PMT), this study explored whether the number of total COVID-19 cases/deaths and general anxiety were associated with cross-situational handwashing adherence and whether these associations were mediated by PMT-specific self-regulatory cognitions (threat appraisal: perceived vulnerability, perceived illness severity; coping appraisal: self-efficacy, response efficacy, response costs).

METHOD

The study (#NCT04367337) was conducted in March-September 2020 among 1256 adults residing in 14 countries. Self-reports on baseline general anxiety levels, handwashing adherence across 12 situations, and PMT-related constructs were collected using an online survey at two points in time, four weeks apart. Values of COVID-19 cases and deaths were retrieved twice for each country (one week prior to the individual data collection).

RESULTS

Across countries and time, levels of adherence to handwashing guidelines were high. Path analysis indicated that smaller numbers of COVID-19 cases/deaths (Time 0; T0) were related to stronger self-efficacy (T1), which in turn was associated with higher handwashing adherence (T3). Lower general anxiety (T1) was related to better adherence (T3), with this effect mediated by higher response efficacy (T1, T3) and lower response cost (T3). However, higher general anxiety (T1) was related to better adherence via higher illness severity (T1, T3). General anxiety was unrelated to COVID-19 indicators.

CONCLUSIONS

We found a complex pattern of associations between the numbers of COVID-19 cases/deaths, general anxiety, PMT variables, and handwashing adherence at the early stages of the pandemic. Higher general anxiety may enable threat appraisal (perceived illness severity), but it may hinder coping appraisal (response efficacy and response costs). The indicators of the trajectory of the pandemic (i.e., the smaller number of COVID-19 cases) may be indirectly associated with higher handwashing adherence via stronger self-efficacy.

Factors Associated with Handwashing Behaviors During the COVID-19 Pandemic: An Analysis of the Community Health Survey in Korea

Introduction

Handwashing is the most effective preventive behavior for coronavirus disease-19 (COVID-19) infection. However, research has shown the lower handwashing behaviors among Korean adults.

Objectives

This study aims to analyze factors associated with handwashing as a preventive behavior for COVID-19 infection based on the health belief model (HBM) and the theory of planned behavior (TPB) behavioral theories.

Methods

This secondary data analysis utilized the Community Health Survey developed by Disease Control and Prevention Agency conducted in 2020. Sampling method was stratified and targeted 900 people living in the territory of each community public health center. In total, 228,344 cases were used in the analysis. Handwashing behavior, perceived susceptibility, perceived severity, subjective norm, and influenza vaccine uptake were used in the analysis. Regression analysis using weighing strategy by stratification and domain analysis was used.

Results

Less washing hand was associated with older age (B = 0.01, p < .001), males (B = 0.42, p < .001), not receiving an influenza vaccine (B = 0.09, p < .001), perceived susceptibility (B = 0.12, p < .001), subjective norm (B = 0.05, p < .001), and perceived severity (B = -0.04, p < .001).

Conclusion

While perceived susceptibility and social norm had positive association, perceived severity had a negative association with handwashing. Considering the Korean culture, creating a shared norm for frequent handwashing could be beneficial to promote handwashing rather than emphasizing the disease and its consequences.

Facilitating hand hygiene in displacement camps during the COVID-19 pandemic: a qualitative assessment of a novel handwashing stand and hygiene promotion package

BACKGROUND

Handwashing with soap is critical for the prevention of diarrhoeal diseases and outbreak related diseases, including interrupting the transmission of COVID-19. People living in large displacement settings are particularly vulnerable to such outbreaks, however, practicing handwashing is typically challenging in these contexts.

METHODS

We conducted a qualitative assessment of the implementation of a combined intervention to facilitate handwashing behaviour in displacement camps and in surrounding communities in Bangladesh, Ethiopia and the Democratic Republic of Congo during the COVID-19 pandemic. The intervention comprised a 'hardware' infrastructural component (provision of the Oxfam Handwashing Station) and a 'software' hygiene promotion package (Mum's Magic Hands). We used programmatic logbooks, interviews with implementation staff and focus group discussions with crisis-affected populations to assess the use, feasibility and acceptability of the intervention.

RESULTS

Both components of the intervention were viewed as novel and appealing by implementing staff and crisis-affected populations across the study sites. The acceptability of the handwashing station could be improved by redesigning the tap and legs, exploring local supply chain options, and by providing a greater number of facilities. The implementation of the hygiene promotion package varied substantially by country making it challenging to evaluate and compare. A greater focus on community engagement could address misconceptions, barriers related to the intuitiveness of the handwashing station design, and willingness to participate in the hygiene promotion component.

CONCLUSIONS

The combination of a 'hardware' and 'software' intervention in these settings appeared to facilitate both access and use of handwashing facilities. The acceptability of the combined intervention was partially because a great deal of effort had been put into their design. However, even when delivering well-designed interventions, there are many contextual aspects that need to be considered, as well as unintended consequences which can affect the acceptability of an intervention.

Knowledge and practices toward COVID-19 among healthcare students: A cross-sectional study at the University of Zambia

Background

The COVID-19 pandemic led to the disruption of physical classes for university students globally, as large gatherings fuelled the transmission of the virus. In the efforts to mitigate its transmission and return to normality, prevention measures, including vaccination, have been encouraged. Therefore, it is critical to understand the knowledge and practices of students regarding COVID-19. This study assessed the knowledge and practices toward COVID-19 among healthcare students at the University of Zambia.

Materials and methods

This questionnaire-based cross-sectional study was carried out from August 2021 to October 2021 among 478 healthcare students (pharmacy, physiotherapy, nursing, biomedical, medicine, and radiography). We used a previously validated questionnaire to measure knowledge and practice. The predictors of knowledge and practices were assessed using logistic regression with robust estimation of standard errors. Statistical analysis was conducted using Stata/BE version 17.0.

Results

Of the 478 respondents, 243 (50.8%) were females. A larger proportion, 175 (36.6%) were in Pharmacy training, and 156 (32.6%) were in their fifth year of study. The overall mean knowledge score of the participants was 87.9 (SD = 16.1), being higher at 89.6 (SD = 14.3) among medical students and the lowest at 86.7 (SD = 17.1) among Pharmacy students, although this was statistically non-significant (p = 0.488). The overall mean practice score was 60.0 (SD = 24.7), being significantly higher at 63.5 (23.4) among nursing, physiotherapy and environmental students compared to other students (p = 0.048). In multivariable analysis, the participant training program was non-significantly associated with knowledge and practice toward COVID-19. However, increased age (AOR = 1.09, 95% CI: 1.01-1.117) and residing in urban areas (AOR = 1.79, 95% CI: 1.07-3.01) than in rural areas were associated with higher odds of good practice toward COVID-19.

Conclusion

The healthcare students generally showed good knowledge levels and poor practices toward COVID-19. Further, there was no evidence of a difference in knowledge of COVID-19 among healthcare students. These findings suggest the need for implementation strategies to be centered on improving the practices of students toward COVID-19.

"I Can Sense When My Hands Need Washing": A Qualitative Study and Thematic Analysis of Factors Affecting Young Adults' Hand Hygiene

Handwashing is one of the most effective and low-cost public health measures. However, it is often not practiced frequently enough or correctly by the public. Young adults in particular have poorer intentions to wash their hands, frequency of handwashing, and sanitizer use compared to other age groups. Therefore, there is a need to identify barriers and facilitators affecting hand hygiene within this group. The objective of this qualitative study was to apply the Theoretical Domains Framework to explore factors which influence hand hygiene among young adults aged 18 to 25 years old. An online questionnaire (n = 37) and thematic analysis were used to generate 3 overarching themes. The main findings indicated internal factors such as knowledge and intentions; interpersonal factors such as social norms; and environmental factors such as reminders, cues, accessibility, and cleanliness of handwashing facilities determined the level of hand hygiene practiced among young adults. The findings suggest that behavior change techniques such as social comparisons and tailored messaging to suit the needs of young adults may be more effective at increasing hand hygiene.

Socioeconomic-Related Inequalities in COVID-19 Vulnerability in South Africa

Individuals' vulnerability to the risk of COVID-19 infection varies due to their health, socioeconomic, and living circumstances, which also affect the effectiveness of implementing non-pharmacological interventions (NPIs). In this study, we analysed socioeconomic-related inequalities in COVID-19 vulnerability using data from the nationally representative South African General Household Survey 2019. We developed a COVID-19 vulnerability index, which includes health and social risk factors for COVID-19 exposure and susceptibility. The concentration curve and concentration index were used to measure socioeconomic-related inequalities in COVID-19 vulnerability. Recentred influence function regression was then utilised to decompose factors that explain the socioeconomic-related inequalities in COVID-19 vulnerability. The concentration index estimates were all negative and highly significant (p < 0.01), indicating that vulnerability to COVID-19 was more concentrated among the poor. According to the decomposition analysis, higher income and education significantly (p < 0.01) positively impacted lowering socioeconomic-related COVID-19 vulnerability. Living in an urban region, being Black, and old all had significant (p < 0.01) positive impacts on increasing socioeconomic-related COVID-19 vulnerability. Our findings contribute to a better understanding of socially defined COVID-19-vulnerable populations in South Africa and the implications for future pandemic preparedness plans.

Political ideology predicts preventative behaviors and infections amid COVID-19 in democracies

Can one's political ideology predict his or her testing positive for COVID-19 and how? The present study leveraged a recent (April–May 2020) survey of 27,260 individuals across 27 democracies to investigate the associations between political ideology and coronavirus infections. Our individual-level data and mediation analyses allow us to tease out different correlational paths according to which one's political ideology affects his or her infection. We found a more right-leaning attitude to be associated with a higher probability of testing positive both directly and indirectly through conspiracy theory beliefs and physical distancing. Moreover, our cross-national investigation also found that becoming more right-leaning in ideology was associated with a higher level of perceived risk of COVID-19 infection, which made one less likely to test positive. Combined, we provide a more nuanced understanding of the role played by political ideology in the current pandemic, on which the design of a more effective risk communication strategy can be based.

How does handwashing behaviour change in response to a cholera outbreak? A qualitative case study in the Democratic Republic of the Congo

Background

Handwashing with soap has the potential to curb cholera transmission. This research explores how populations experienced and responded to the 2017 cholera outbreak in the Democratic Republic of the Congo and how this affected their handwashing behaviour.

Methods

Cholera cases were identified through local cholera treatment centre records. Comparison individuals were recruited from the same neighbourhoods by identifying households with no recent confirmed or suspected cholera cases. Multiple qualitative methods were employed to understand hand hygiene practices and their determinants, including unstructured observations, interviews and focus group discussions. The data collection tools and analysis were informed by the Behaviour Centred Design Framework. Comparisons were made between the experiences and practices of people from case households and participants from comparison households.

Results

Cholera was well understood by the population and viewed as a persistent and common health challenge. Handwashing with soap was generally observed to be rare during the outbreak despite self-reported increases in behaviour. Across case and comparison groups, individuals were unable to prioritise handwashing due to competing food-scarcity and livelihood challenges and there was little in the physical or social environments to cue handwashing or make it a convenient, rewarding or desirable to practice. The ability of people from case households to practice handwashing was further constrained by their exposure to cholera which in addition to illness, caused profound non-health impacts to household income, productivity, social status, and their sense of control.

Conclusions

Even though cholera outbreaks can cause disruptions to many determinants of behaviour, these shifts do not automatically facilitate an increase in preventative behaviours like handwashing with soap. Hygiene programmes targeting outbreaks within complex crises could be strengthened by acknowledging the emic experiences of the disease and adopting sustainable solutions which build upon local disease coping mechanisms.