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

Astrid Hasund Thorseth, Thomas Heath, Andualem Sisay, Mare Hamo, Sian White, Astrid Hasund Thorseth, Thomas Heath, Andualem Sisay, Mare Hamo, Sian White

Abstract

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 ).

Keywords: Behaviour change; Conflict; Ethiopia; Handwashing; Hygiene kit; Internally displaced persons; Soap.

Conflict of interest statement

The authors and their institutions have no financial or other conflicts of interest.

Figures

Fig. 1
Fig. 1
Study design of the 4-armed exploratory pilot study of the effect of modified hygiene kits on handwashing with soap among internally displaced persons in Moyale District, Ethiopia
Fig. 2
Fig. 2
Picture a, b and c display the handwashing facilities distributed in all four study arms. Picture a shows a handwashing facility and liquid soap from IA1-Liquid, picture b shows a handwashing facility and a scented soap bar laying on top of the facility in IA2-Scented, and picture c shows a mirror and handwashing facility as distributed in IA3-Mirror
Fig. 3
Fig. 3
The soaps used for a soap ranking activity in focus group discussions. These soaps were purchased at a local market in Moyale District, Ethiopia

References

    1. Connolly MA, Gayer M, Ryan MJ, Salama P, Spiegel P, Heymann DL. Communicable diseases in complex emergencies: impact and challenges. Lancet. 2004;364(9449):1974–1983. doi: 10.1016/S0140-6736(04)17481-3.
    1. UNICEF . Water under fire. 2019.
    1. Ramesh A, Blanchet K, Ensink JHJ, Roberts B. Evidence on the Effectiveness of Water, Sanitation, and Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic Review. PLoS One. 2015;10(9):e0124688. doi: 10.1371/journal.pone.0124688.
    1. Cronin AA, Shrestha D, Spiegel P, Gore F, Hering H. Quantifying the burden of disease associated with inadequate provision of water and sanitation in selected sub-Saharan refugee camps. J Water Health. 2009;7(4):557–568. doi: 10.2166/wh.2009.089.
    1. Hammer CC, Brainard J, Hunter PR. Risk factors and risk factor cascades for communicable disease outbreaks in complex humanitarian emergencies: a qualitative systematic review. BMJ Glob Health. 2018;3(4):e000647. doi: 10.1136/bmjgh-2017-000647.
    1. Behnke NL, Cronk R, Shackelford BB, Cooper B, Tu R, Heller L, Bartram J. Environmental health conditions in protracted displacement: a systematic scoping review. Sci Total Environ. 2020;726:138234. doi: 10.1016/j.scitotenv.2020.138234.
    1. Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. Am J Public Health. 2008;98(8):1372–1381. doi: 10.2105/AJPH.2007.124610.
    1. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, et al. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Tropical Med Int Health. 2014;19(8):906–916. doi: 10.1111/tmi.12339.
    1. Curtis V, Cairncross S. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis. 2003;3(5):275–281. doi: 10.1016/S1473-3099(03)00606-6.
    1. Wolf J, Hunter PR, Freeman MC, Cumming O, Clasen T, Bartram J, Higgins JPT, Johnston R, Medlicott K, Boisson S, Prüss-Ustün A. Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression. Tropical Med Int Health. 2018;23(5):508–525. doi: 10.1111/tmi.13051.
    1. White S, Thorseth AH, Dreibelbis R, Curtis V. The determinants of handwashing behaviour in domestic settings: an integrative systematic review. Int J Hyg Environ Health. 2020;227:113512. doi: 10.1016/j.ijheh.2020.113512.
    1. Wolf J, Johnston R, Freeman MC, Ram PK, Slaymaker T, Laurenz E, et al. Handwashing with soap after potential faecal contact: global, regional and country estimates. Int J Epidemiol. 2018;48(4):1204–1218. doi: 10.1093/ije/dyy253.
    1. Phillips RM, Vujcic J, Boscoe A, Handzel T, Aninyasi M, Cookson ST, Blanton C, S Blum L, Ram PK. Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan. Confl Health. 2015;9(1):39. doi: 10.1186/s13031-015-0065-2.
    1. De Buck E, Van Remoortel H, Hannes K, Govender T, Naidoo S, Avau B, et al. Approaches to promote handwashing and sanitation behaviour change in low- and middle income countries: a mixed method systematic review. Campbell Syst Rev. 2017;7:1–447
    1. Yates TAJ, Joseph M, Lantagne D. Short-term WASH interventions in emergency response: a systematic review. London: International lnitative for Impact Evaluation (3ie); 2017.
    1. Association S. The sphere handbook: humanitarian charter and minimum standards in humanitarian response. 4th ed. Geneva: Practical Action Publishing; 2018.
    1. Gauthier J. A real-time evaluation of ACF’s response to cholera emergency in juba, South Sudan Evaluation report. 2014.
    1. UNICEF . Cholera Toolkit. 2013.
    1. Frontières MS . Management of A CHOLERA EPIDEMIC. 2018.
    1. Jodar J, Kondakhchyan A, McCormack R, Peachey K, Phelps L, Smith G. The State of the World’s Cash 2020 – Full report. 2020.
    1. Peterson EA, Roberts L, Toole MJ, Peterson DE. The effect of soap distribution on diarrhoea: Nyamithuthu refugee camp. Int J Epidemiol. 1998;27(3):520–524. doi: 10.1093/ije/27.3.520.
    1. Biran A, Schmidt WP, Zeleke L, Emukule H, Khay H, Parker J, Peprah D. Hygiene and sanitation practices amongst residents of three long-term refugee camps in Thailand, Ethiopia and Kenya. Tropical Med Int Health. 2012;17(9):1133–1141. doi: 10.1111/j.1365-3156.2012.03045.x.
    1. D’Mello-Guyett L, Greenland K, Bonneville S, D’hondt R, Mashako M, Gorski A, Verheyen D, van den Bergh R, Maes P, Checchi F, Cumming O. Distribution of hygiene kits during a cholera outbreak in Kasaï-oriental, Democratic Republic of Congo: a process evaluation. Confl Heal. 2020;14(1):51. doi: 10.1186/s13031-020-00294-w.
    1. George CM, Monira S, Sack DA, Rashid M-U, Saif-Ur-Rahman KM, Mahmud T, et al. Randomized controlled trial of hospital-based hygiene and water treatment intervention (CHoBI7) to reduce cholera. Emerg Infect Dis. 2016;22(2):233–241. doi: 10.3201/eid2202.151175.
    1. Blum LS, Yemweni A, Trinies V, Kambere M, Tolani F, Allen JV, Handzel T, Cookson S, Ram PK. Programmatic implications for promotion of handwashing behavior in an internally displaced persons camp in north Kivu, Democratic Republic of Congo. Confl Heal. 2019;13(1):54. doi: 10.1186/s13031-019-0225-x.
    1. White S, Petz JF, Desta K, Holm LT. Could the Supertowel be used as an alternative hand cleaning product for emergencies? An acceptability and feasibility study in a refugee camp in Ethiopia. PLoS One. 2019;14(5):e0216237. doi: 10.1371/journal.pone.0216237.
    1. Gartley M, Valeh P, de Lange R, Dicarlo S, Viscusi A, Lenglet A, et al. Uptake of household disinfection kits as an additional measure in response to a cholera outbreak in urban areas of Haiti. J Water Health. 2013;11(4):623–628. doi: 10.2166/wh.2013.050.
    1. Briere EC, Ryman TK, Cartwright E, Russo ET, Wannemuehler KA, Nygren BL, Kola S, Sadumah I, Ochieng C, Watkins ML, Quick R. Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers. J Infect Dis. 2012;205(Suppl 1):S56–S64. doi: 10.1093/infdis/jir779.
    1. Ram P. Practical Guidance for Measuring Handwashing Behavior: 2013 Update. Water and Sanitation Programme Website. 2013.
    1. Shackelford BB, Cronk R, Behnke N, Cooper B, Tu R, D'Souza M, Bartram J, Schweitzer R, Jaff D. Environmental health in forced displacement: a systematic scoping review of the emergency phase. Sci Total Environ. 2020;714:136553. doi: 10.1016/j.scitotenv.2020.136553.
    1. The Brookings Institution . Under the Radar: Internally Displaced Persons in Non-Camp Settings. Washington DC: Brookings-LSE; 2013.
    1. Hirai M, Graham JP, Mattson KD, Kelsey A, Mukherji S, Cronin AA. Exploring determinants of handwashing with soap in Indonesia: a quantitative analysis. Int J Environ Res Public Health. 2016;13(9):868.
    1. Group M . Soap, Bath and shower products. 2016.
    1. Jenkins MW, Anand AR, Revell G, Sobsey MD. Opportunities to improve domestic hygiene practices through new enabling products: a study of handwashing practices and equipment in rural Cambodia. Int Health. 2013;5(4):295–301. doi: 10.1093/inthealth/iht026.
    1. Partnership GH. Partnership GH, editor2017. [cited 30.06.2020]. Available from: .
    1. Affairs UNOftCoH . Ethiopia. Access Snapshot - Southern Oromia. 2019.
    1. Operations ECPaHA. ECHO Daily Flash 21 December 2018 2018 [Available from: . Accessed 19 June 2020.
    1. Organisation WH. Ethiopia - Response for Acute Watery Diarrhea outbreak in Moyale town. Available from: . Accessed 13 May 2020.
    1. Cluster H. Ethiopia Health Cluster Bulletin #12 January 2020 2020 [Available from: .
    1. International Organisation of Migraion. Ethiopia. Displacement Tracking Matrix. Ethiopia - Site Assessment Round 18. Ethiopia: International Organisation for Migration; 2019. Available from: .
    1. Joint Monitoring Programme U. Hygiene: Joint Monitoring Programme. New York: UNICEF; 2020. Available from: .
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
    1. Dreibelbis R, Kroeger A, Hossain K, Venkatesh M, Ram PK. Behavior Change without Behavior Change Communication: Nudging Handwashing among Primary School Students in Bangladesh. Int J Environ Res Public Health. 2016;13(1).
    1. Williams M. Research summary: behavior change interventions for health habits. 2017.
    1. Biran A, Schmidt WP, Wright R, Jones T, Seshadri M, Isaac P, Nathan NA, Hall P, McKenna J, Granger S, Bidinger P, Curtis V. The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial. Tropical Med Int Health. 2009;14(10):1303–1314. doi: 10.1111/j.1365-3156.2009.02373.x.
    1. Wolf J, Johnston R, Freeman MC, Ram PK, Slaymaker T, Laurenz E, Prüss-Ustün A. Handwashing with soap after potential faecal contact: global, regional and country estimates. Int J Epidemiol. 2019;48(4):1204–1218. doi: 10.1093/ije/dyy253.
    1. Ram PK, Halder AK, Granger SP, Jones T, Hall P, Hitchcock D, et al. Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation. Am J Trop Med Hyg. 2010;83(5):1070–1076. doi: 10.4269/ajtmh.2010.09-0763.
    1. Schmidt WP, Lewis HE, Greenland K, Curtis V. Comparison of structured observation and pictorial 24 h recall of household activities to measure the prevalence of handwashing with soap in the community. Int J Environ Health Res. 2019;29(1):71–81. doi: 10.1080/09603123.2018.1511772.
    1. Biran A, Schmidt WP, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, Gopalan B, Aunger R, Curtis V. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health. 2014;2(3):e145–e154. doi: 10.1016/S2214-109X(13)70160-8.

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