Astrid Hasund Thorseth, Thomas Heath, Andualem Sisay, Mare Hamo and Sian White
Crisis-affected populations are at increased risk of diarrhoeal morbidity and mortality and in conflict-affected settings, children under 5 years of age are 20 times more likely to die from diarrheal disease than from violence associated with the conflict itself. This is because crises often force populations to be displaced to crowded, informal living environments enabling diseases to spread more easily from one person to the next. At the same time, many of the institutions, infrastructure and social support systems that would normally support health break down, resulting in decreased diagnoses and treatment and increases in disease severity. Inadequate access to water, sanitation and hygiene (WASH) remains a global challenge, but these challenges are particularly pronounced in crisis-affected regions.
The seemingly simple act of handwashing with soap (HWWS) is associated with a 23–47% reduction in diarrhoea morbidity and up to a 25% reduction in respiratory illness. Convenient access to handwashing soap products and handwashing facilities is a crucial determinant for enabling handwashing behaviours. Handwashing facilities with water and soap present, act as a reminder or cue to perform HWWS at critical times. When infrastructure is lacking, the perceived psychological trade-off (for example, perceiving handwashing to be a strenuous physical endeavour) can make HWWS less likely to be performed. During humanitarian crises, the determinants of handwashing behaviour may differ from stable settings, because crises typically cause considerable disruptions of cultural and habitual norms. Such circumstances may compromise health-protecting behaviours, such as HWWS, due to the multitude of other challenges facing populations. However, evidence about these behavioural shifts or the determinants of handwashing behaviour during crises remains limited.
Humanitarian crises differ from stable settings in other important ways. In a crisis, humanitarian actors typically provide hygiene items to populations rather than assuming communities can provide this themselves (as is the case in stable settings). The Sphere Standards for Humanitarian Action provides a minimum list of items to be included in hygiene kits including water containers, soap for bathing, soap for laundry, a handwashing station per household or a handwashing station with soap and water at shared toilet facilities and items to aid the safe disposal of children’s faeces. However, there is no standard definition of hygiene kits and the type, quantity and quality of the components vary widely between organisations. The items included in hygiene kits can also vary based on the context they are being distributed. This can be influenced by the feasibility of transporting or procuring items for populations that are fleeing, population needs (e.g. water treatment products in areas experiencing cholera outbreaks), population preferences around hygiene products and WASH cluster standards. There is an increasing trend of distributing cash or voucher-based assistance in combination or instead of hygiene kits or products.
Hygiene kits aim to reduce the risk of disease transmission by encouraging the increased practice of hygiene behaviours at the household level. However, there is limited evidence about the acceptability of hygiene kits, the use of hygiene kit products by crisis-affected populations and the effect of hygiene kit distributions on behaviour or health outcomes. The available evidence is predominantly focused upon soap and hygiene kit distributions in camp settings or cholera outbreaks, and has documented mixed results. One study in Bangladesh distributed hygiene kits to cholera cases upon discharge from treatment centres and showed promising impacts on behaviour and health outcomes. The majority of other studies have focused on the feasibility of distributing hygiene kits, highlighting the challenges achieving sufficient coverage of the population. Many of the studies of soap and hygiene kit distributions rely on self-reported measures or proxy measures of product use and behaviour, which are considered less reliable indicators of handwashing behaviour. Given this current state of evidence, a recent systematic review of health interventions for emergency settings called for further research into the behaviour change potential of hygiene kit components, particularly soap.
Internally displaced persons (IDPs) residing outside of camps are systematically less studied due to the complexities of researching in these settings. A 2020 systematic review of all WASH literature published about crisis-affected settings, reported that only 17% related to populations residing outside of camps, and 41% relates to IDP populations. This is concerning given that in 2019 there were 15.4 million more IDPs than refugees globally and an estimated 29 million IDPs live in out-of-camp settings. In these out-of-camp settings, IDPs are often overlooked by governments and non-government organisations, increasing their vulnerability.
Our study aimed to explore the potential to increase HWWS soap at critical times among IDPs living in an out-of-camp setting using locally available and rapidly deployable hygiene kit interventions. The pilot was also designed to explore if minor modifications to the quality of hygiene kit products could make HWWS more desirable and increase the likelihood it’s practised at critical times. We tested the inclusion of a scented soap bar, liquid soap or mirrors within the hygiene kits distributed by Action Against Hunger (AAH). The soap bars tested differs from standard soap bar included in AAH’s hygiene kits in three important ways: the soap was scented (whereas their standard soap bar was not), the soap had olive oil extracts in it, which was intended to make hands feel smoother after use (according to the manufacturer) and the cost of the soap was higher than the standard soap bar. The desire to smell nice has been found to motivate HWWS and therefore this was included as an intervention in our study. Our rationale for choosing liquid soap as an intervention was based on global soap usage patterns; use of soap bar in stable and higher income settings is declining, and liquid soap now accounts for 47% of personal soap use. A study of perceptions of soap bars in the US found that over half of consumers found liquid soap more convenient to use than soap bars, and 48% of consumers believed germs would remain on a soap bar after use. We also hypothesised that changes to the physical environment surrounding the handwashing facility could cue behaviour and make it seem more desirable and therefore result in handwashing facilities being used more frequently or for a longer duration. We distributed a mirror with the hygiene kits to be placed over the handwashing station to test this. Adding a mirror is hypothesised to make a handwashing facility more desirable, but its effect on handwashing behaviour has been poorly documented to date.