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South Sudan + 1 more

Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan

Attachments

Raina M Phillips*, Jelena Vujcic, Andrew Boscoe, Thomas Handzel, Mark Aninyasi, Susan T Cookson, Curtis Blanton, Lauren S Blum and Pavani K Ram

Abstract

Background

Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County.

Methods

We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission.

Results

Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available “always” or “sometimes”. Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including “before eating” (80 % rinsing vs. 7 % washing with soap) and “before preparing/cooking food” (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone.

Conclusions

Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions.

Background

Overcrowded conditions, poor nutrition, and limited water, sanitation, and hygiene (WASH) facilities put refugees at high risk for communicable disease outbreaks, especially diseases transmitted by the fecal-oral route such as diarrhea and viral hepatitis A and E. In one meta-analysis, handwashing with soap has been shown to reduce diarrhea risk by 31 % and acute respiratory infection risk by 21 % [1]. Washing with soap is more effective at hand decontamination than washing with water alone [2]–[4].

Studies on handwashing frequency, motivators, and barriers have primarily been performed in stable developing country contexts [5]. Curtis et al. performed an eleven country study and found in structured observations that 17 % of caregivers washed hands with soap after defecation, while 45 % rinsed hands with water alone [5]. However, in the setting of internal displacement or among refugees, habit and cultural norms can be disrupted, thereby potentially altering practices such as handwashing. There is a dearth of information on handwashing frequency, motivators and barriers in refugee settings. A study in three refugee camps by Biran et al. (in Kenya, Ethiopia and Thailand) found that soap was used for handwashing after 20 % of toilet use events [6]. In qualitative research, they found that barriers to handwashing included lack of free soap and preference to use soap for laundry. They concluded that handwashing rates were suboptimal despite hygiene education in the camps [6]. A study in a Malawian refugee camp on soap presence and diarrhea found the presence of soap in households to be protective against diarrhea, suggesting the soap was being used for handwashing, however structured observation was not performed to verify this practice [7].

Maban County, Upper Nile State, South Sudan experienced an influx of refugees escaping violence and civil unrest in Sudan beginning in November 2011. As of December 2013, approximately 124,000 registered refugees lived in four camps in Maban County: Kaya, Yusuf Batil, Doro, and Gendrassa [8], [9]. In 2012, a large outbreak of hepatitis E virus (HEV) occurred among refugees in all four of the camps. Approximately 11,000 persons were symptomatic with HEV and, among them, 238 deaths occurred [8]. In response to the HEV outbreak, non-governmental organizations (NGOs) increased hygiene promotion efforts including messaging about handwashing, soap use, and HEV transmission.

The four camps varied in size and demographics. Doro was predominantly Christian while Kaya, Batil, and Gendrassa were predominantly Muslim. The hepatitis E outbreak disproportionately affected individuals in Batil and what is now Kaya camp due to their physical locations in a floodplain. Different organizations were in charge of WASH activities for each camp and, thus, some camps had more handwashing stations built, others had better family:latrine ratios, and clean water provision was a priority in all camps. Latrines and, if present, handwashing stations, were shared among multiple compounds of families in each camp. The hygiene promotion also varied from camp to camp in response to the outbreak. While all agencies focused on improving access to clean water, other interventions included posters depicting important times to wash hands with soap, community health workers who provided family and school level messaging regarding handwashing, and increasing latrine and handwashing station access. The amount of soap distributed to each household monthly increased equally amongst all camps.

In this study, we sought to describe the knowledge, attitudes, and practices among the refugees in three camps in Maban County 1 year after the scale up of hygiene education, increased soap distribution, and improved sanitation measures in response to the HEV outbreak. We also sought to examine the motivators and barriers to handwashing with soap including access to latrines and soap and beliefs about disease risk and transmission. Finally, we aimed to compare self-reported practices with the observed rates of handwashing with soap and rinsing with water at critical times for pathogen transmission to assess the validity of self-reported handwashing behavior compared to directly observed behavior.