CAWST has been working with Action Contre Faim (ACF) and The London School of Hygiene and Tropical Medicine (LSHTM) to better understand handwashing practices among internally displaced people. Working together on this project, our partnership brings together our experience and networks in academic health research, humanitarian operational experience in WASH and Mental Health, and development of educational material. The general objective of the research is to develop deep understandings of the determinants of hand hygiene in emergency settings, thus contributing to the development of rapid and effective intervention tools; the ultimate goal of the research will be to equip emergency responders with the knowledge and tools to intervene rapidly and effectively on hygiene behaviour. Phase 1 of this project explores the determinants of hygiene behaviour in these contexts. To fulfill the objectives of this phase, exploratory field work was carried out in Iraq and the Democratic Republic of Congo (DRC). Phase 2 will involve developing a software-based decision-making tool to aid in the design of rapid, evidence-based programs.
The full findings, including practitioner resources, will be available in 2018.
In her earlier blog post, Sian White, the project’s lead researcher, shared four research methods she has been using and what these had revealed so far in her exploratory fieldwork in Iraq. In this update, Sian discusses the work done in Iraq and DRC, including the research objectives and methods used and some of the key findings from the qualitative research.
Study sites: Iraq and DRC
Since 2014, four million Iraqis are estimated to have been displaced due to conflict. The study sites for this research were the Dohuk and Ninewa Governorates (boundaries between these areas were disputed at the time as shown on the map opposite). The research took place during the final period of the battle for Mosul. The interviews with humanitarian actors took place in Erbil and Dohuk cities as these are the primary locations where organisations and coordinating bodies were based at the time.
Cholera has been endemic in DRC since 1994. In the eastern provinces of North and South Kivu, cases are registered throughout the year with peaks at the end of the dry season. However, in 2017 DRC experienced its worst cholera outbreak in decades with almost 50,000 suspected cases and over 900 deaths registered between January and December. Although the outbreak spread across 21 of the nation’s 26 provinces, the Kivus were the worst affected. Minova, where the research took place, sits alongside Lake Kivu, a renowned reservoir for vibro cholera. There are also two informal IDP camps in Minova and many other IDPs living in the community.
Objectives of the work in Iraq and DRC
1. Describe the determinants of handwashing behaviour:
• during and after mass displacement due to an armed conflict (Iraq).
• during a cholera outbreak in a context which also experiences ongoing conflict and population displacement (DRC).
2. Understand how humanitarian actors currently design hygiene programs and identify the constraints within which they have to operate.
3. Pilot and refine a set of rapid and simple formative research methods that could be replicated by humanitarian practitioners with limited experience and guidance.
The research was designed based on the Behaviour Centred Design framework (Aunger and Curtis, 2016). This framework outlines a set of behavioural determinants. For each of these a handwashing specific definition of the determinant was developed as an output of the literature review. By reviewing handwashing literature and looking more broadly a method was then selected to explore each determinant in the framework.
Method Reflections – Iraq
Most of the methods were well accepted and were found to be appropriate to this context. Two methods were not used from the outset. The first was observation at communal waterpoints as these did not exist in these settings. The second was the behaviour trails method. This deemed in appropriate in the first camp in particular as people could not control their environments or circumstances and this is a highly participatory method that requires participants to actively make changes that would enable handwashing. The other method that was used with a small number of participants but then stopped was the social network mapping. This was a highly sensitive method as it reminded people of friendships and family they had lost/been separated from and the researchers felt that it had the potential to cause discomfort. Some of the methods that worked particularly well were observation, the 100 people activity, soap attribute ranking, the ideal handwashing facility activity and the personal histories activity. The latter was created for this research but proved useful for understanding the broader context as well as how hygiene practices changed over time.
Method reflections – DRC
Most of the methods were well accepted and were found to be appropriate to this context. Some of the methods that worked particularly well were the behaviour trials, the soap attribute ranking, the motive characters, the water prioritisation and the personal histories method. Observation was particularly challenging in this context because shelters were very small and dark, thus making it hard for the research assistants to position themselves in a discrete location. The lead researcher also had to cease participating in the observation (leaving it to the local staff) as the presence of a foreigner in the community tended to cause a lot of disruption and cause crowds to gather. Some of the methods took longer to do in this context because lower levels of literacy necessitating longer explanations.
Key preliminary findings from the qualitative research – Iraq
The situation in the short-term camp
Contrary to the research hypothesis, handwashing appeared to increase among those displaced to camps. This was due to a confluence of factors. The first factor was that in both camps there was no restriction on water use, which is relatively unusual compared to other camps globally. Secondly, we conducted the study at the height of summer when the temperatures are extremely hot and the environment very dusty, thus people got sweaty and unclean quickly. Thirdly people had relatively few possessions and as such clothes, dishes and household spaces needed to be cleaned regularly. Fourthly, people reported a heightened sense of disease risk since coming to the camp and diarrhoea was cited as a leading concern. Lastly, there was very little for people to do in the camps. People tended to avoid socializing (particularly in the immediate period following displacement) and endeavoured to re-establish their routines and create more comfortable and orderly spaces within their households (often re-designing their shelters to make them more like home). In the absence of other tasks, cleaning behaviours became a predominant part of daily life. These circumstances created an environment where people frequently came into contact with water and where hygiene was highly valued. However, these circumstances may have created a false sense of cleanliness. Hands were often not washed with soap nor was handwashing practiced at all critical times. In particular we did not observe handwashing prior to food preparation or eating. In the short-term camp where WASH facilities were shared, handwashing with soap was less common as soap was normally stored inside people’s tents rather than near the bathroom (this was because people worried about it being stolen or used carelessly).
The situation in the long-term camp
Perceived risk is normally understood to diminish with time as people become accustomed to their new situation. Surprisingly this was not found to be the case in the long-term displacement camp, with people still feeling at increased risk of diarrhoea. The circumstances described above (availability of water, the heat, the lack of belongings, and lots of time) were present in this camp too and this appears to have led to the creation of a new hygiene norm. In addition, several years of hygiene kit distributions have created a demand for soap even though hygiene products are no longer distributed. People reported spending a large portion of their income on hygiene products, it was stockpiled, available in all homes, and used excessively in day-to-day activities. In this setting the perceived quality of the water (it was of drinkable quality but had lots of minerals) was a barrier to regular handwashing as people felt it left a salty residue and led to their hands being dry and irritated.
The situation in the villages
In the villages hygiene behaviour was different from camps and varied depending on whether individuals were returnees or were IDPs. For returnees being back home was accompanied with feeling safe and protected. As a consequence, people were more likely to think that diarrhoea was not a risk to their families, that it was uncommon in their villages and not something to be scared of. However, people were returning to homes and communities that were different to those they left. For example, buildings had been destroyed and possessions looted; the water supply had been cut and so people had shifted from piped water to collecting a limited amount of water in jerry cans; people were unemployed; and markets (including those that sold soap) had ceased operation. Handwashing was uncommon in these settings and many families did not have soap in their households. Despite this there was a desire among returnees to ‘build back more beautiful’ and to maintain their own appearance despite their circumstances. In communities, people tended to have dedicated places for handwashing. In most cases these were beautifully appointed ceramic basins, with piped water, a soap dish and a mirror. The basins were prominently located near the front of the house for guests to use. However almost all basins were damaged or non-functional due to the lack of water supply, making it harder and less appealing to wash hands. IDPs residing among returnee communities explained that hygiene was of utmost importance to their identity. They felt that being an IDP meant others were likely to label them as unclean and poor. They explained that they had made paid attention to the hygiene norms of others in the community and had actively taught their children that they must be more hygienic than the community members so as to create the right impression.
Implications for Practitioners
• Knowledge: Almost everyone understood the association between handwashing and disease transmission. This means that we can stop educating people about disease transmission as part of programs.
• Behavioural settings: In this context people are used to beautiful facilities for handwashing. Camps and rebuilding efforts in villages, should aim to re-create and enhance this. This should involve creating dedicated spaces for handwashing that are pleasant places to be. Facilities should include ‘behavioural nudges’, mirrors and soap dishes. They should be built outside the toilet where it can be seen but where it is still convenient.
• Products: Support the re-establishment of markets so that people in villages can access soap more readily. In camps increase the range of soaps available and allow people to choose the soap they prefer as this will make the product more desirable.
• Norms: In camp settings it is clear that positive handwashing norms exist but that people don’t often observe the behaviour of others. Programs should aim to heighten awareness about positive norms. A simple way of doing this, for example, may be to put up posters that say “Did you know this camp has the highest rates of handwashing of any camp in Kurdistan – Keep it up!”.
• Motives: disgust appears to be naturally heightened in camp settings so improving handwashing in these contexts should rely on linking comfort and attract more closely to handwashing, motives which become increasingly of value when a person has lost so much. To overcome the hygiene complacency observed in villages, disgust should be heightened in order to make people more aware that their home has changed and therefore their behaviour needs to change too.
• Social environment: People do not naturally socialise very much upon arriving at camps, nor do they always receive the necessary psychological support that they require following trauma. Since this research found psychosocial wellbeing to be closely linked to hygiene, hygiene programs could contribute to re-building social support networks and creating spaces where people can talk and interact. Cross-sectional programming between mental health and the WASH sector should be encouraged.
• Delivery channels: Since women are often responsible for key hygiene related tasks but often do not leave the house, all hygiene programs should involve at least some house-to-house component to ensure women feel comfortable and can participate.
Barrier Analysis – Iraq
The qualitative work was complemented with a Barrier Analysis (BA) Survey. Some general reflections on this method:
• This method works very well to complement qualitative research and was also able to confirm some of the qualitative insights (eg. Risk perception).
• This method was good at understanding rational reasons why people do or don’t do the target behaviour but less able to explore behavioural influences that occur at a semi-subconscious level. This is another reason to combine this method with qualitative approaches.
• Screening is based on self-reported and proxy measures of behaviour NOT actual behaviour. In a camp setting people are familiar with hygiene promotion and know the ‘correct’ thing to say.
• The classifications of ‘Doer’ and ‘Non-doer’ are useful because they help to make behaviour simple. But as practitioners we have to remember that these classifications are not reflective of the real-world situation. In reality we all sometimes remember to wash hands and sometimes forget and thus the lines between the categories are more blurry.
Key preliminary findings from the qualitative research – DRC
Observations indicated that handwashing with soap and hand rising (with water alone) were rare in these locations. Handwashing with soap was only observed once among the 17 observation households. Handwashing rarely took place after using the toilet but hand rinsing was sometimes practiced before eating, and this was actively taught to children as part of good mannerly behaviour. Hands rinsing was most often motivated by disgust, that is to say that hands were washed when they were visibly dirty (e.g. after returning from the field). Despite the low prevalence of handwashing behaviour people were well aware of the benefits of handwashing and 98% of participants could explain the association between handwashing and disease transmission.
One of the main factors that prevented convenient handwashing was the absence of handwashing facilities. None of the urban houses we visited had a dedicated place for handwashing. In camps facilities had been built several years ago but were now damaged and non-functional. In rural areas some houses had built tippy-taps (as part of a prior Community-led Total Sanitation campaign) but none were observed to be used or working. In focus groups people reported that they disliked the design of the tippy-taps and saw them as a symbol of poverty that they were not willing to adopt. Both water and soap were considered valuable and therefore people were often reluctant to store them near the toilets or kitchens which were often unclean, shared spaces. During behaviour trials participants identified that one of the barriers to handwashing was that there was nothing to cue behaviour at the key times and this prompted several people to design and build handwashing facilities. They were able to do so in a short period of time, using local materials and at no cost.
Handwashing is not considered to be a worthwhile use of soap. Partly this is because NGOs have promoted the use of ash as a free alternative for handwashing. Handwashing with ash was practiced by some people, but was described as unpleasant and undesirable, resulting in it being used infrequently. Where soap is available in households it is normally laundry powder or laundry bar soap. Although soap is rarely distributed by NGOs, in cases where it is, it is the laundry bar soap that is normally procured. However, participants explained that they would never use this for handwashing as it smells unpleasant and makes their hands dry. In camps and among host community members people live very communally. It is common for people to share containers and tools, share food and give water to a neighbour if they are running low. It was considered acceptable to ask a neighbour for soap to do laundry or for bathing but the idea of asking for soap for handwashing was considered humorous and people reported that you would be seen as trying to be above others if you did so.
In this setting it was common for daily household earnings to be less than $US 2. Daily routines were entirely oriented around earning enough to buy food for that day. With these limited resources adults would normally only eat once a day. People explained that their constant hunger constrained their capacity to remember to be hygienic (for example this was the main reason people said they often forget to wash hands prior to food preparation or eating). In order to earn sufficient money, adults spend most of their day in the fields, leaving young children at home unaccompanied. Parents acknowledged that they were worried about their children’s hygiene during these hours, but felt powerless to change this situation. This suggests that in this context the nurture motive may be less appropriate to utilise to promote handwashing. Although handwashing was a socially desirable behaviour, observed transgressions in handwashing practice were rarely socially sanctioned. This was largely because people normally adopted a forgiving attitude towards such transgressions, assuming that others, like them, must be dealing with poverty, hunger and psychological trauma (due to conflict and displacement). Affiliation (the desire to belong in a social group and therefore conform to group behaviours) did not emerge as a strong motivator of handwashing in this context. During the motives activity people explained that many of their close friends have poor hygiene but this just due to their circumstances rather than their character. In contrast people were judgmental of the handwashing behaviour of their spouse and explained that they could not be attracted to someone if they did not have clean hands. People did think that at a community-level handwashing increased in response to the cholera outbreak. People thought that for the majority of people this would only cause a short-term change in behaviour, but for others it could result in improved habits.
Attitudes and experiences of cholera
All participants were well informed about cholera and able to explain all key transmission routes. In focus group discussions people ranked cholera as the health issue that they were most concerned about and thought that it was the health issue which most commonly affected members of their community. In contrast diarrhoea was considered a mild health issue that did not have severe consequences and was only due to ‘disagreeable food’. Despite this reported ‘fear’ of cholera people simultaneously felt that cholera was just like any other disease and their familiarity with it over the years had allowed them to develop the belief that it could easily be treated (for free) and therefore rarely resulted in death. Consistent with this, many research participants told us that ‘black people don’t die of germs’. This saying was used to rationalise the fact that although most people viewed their environment as dirty and contaminated, and often lacked the means to be hygienic, it was rarely perceived to have adverse consequences. These factors have contributed to cholera no longer being seen as an outbreak disease but rather as a chronic health problem that the population had to manage and tolerate.
Although participants knew that good hygiene practices could reduce the likelihood of getting cholera most people who had contracted cholera felt that in their case it must have been due to bad luck, with the high prevalence of cases causing hygienic people like themselves to fall ill. Since most people knew someone who had had cholera recently there was minimal stigma towards the disease. People perceived it as normal for young children and older people to get cholera – in both cases people explained that this was because it is hard to control their behaviour. However, if healthy adults contracted cholera this was still met with confusion and stigma. Adult cholera cases reported that friends tended not to visit them when they heard they had got cholera. Immediate family and neighbours did not tend to ‘stay away’ nor change their opinion of the person with cholera. These individuals often played an important role in helping the cholera patient to recover. In addition to proximity, this may explain why intra-household transmission and transmission between neighbouring households was common in this region (and is well documented in the literature). Another contributing factor in this region is that cholera case management and follow-up remains suboptimal. On discharge patients are given 7 water treatment tablets and a small bar of laundry soap (although often they do not receive either). Providing such a small amount of hygiene provisions has the effect of distorting people’s risk perception, facilitating beliefs that it is not necessary to sustain good hygiene behaviours in the long term. This is of particular concern given that cholera cases may continue shedding for up to 50 days post discharge.
Although people had strong attitudes towards cholera as a disease, people on average had a poor understanding of the socio-economic impact that it could have on a household. Cholera cases described that they often felt weak and were unable to fulfil their normal tasks for up to a month after being discharged. In a context like DRC where people are generally living in extreme poverty and need to work in order to put food on the table each day, this has a substantial impact on the family economy. With less available of money, people said that they were normally unable to afford products like soap in the weeks after being discharged. Additionally, having a cholera case in the household often meant that the family could not collect as much water as normal (either because the women of the household were personally affected or because they were involved in caring for male household members who were sick). Both of these factors obviously place other family members at higher risk of contracting cholera.
Lastly people tended to associate cholera with people who they viewed to be categorically different from themselves. In focus group discussions people described a typical cholera cases as someone who is already sickly, has little respect for themselves or others, is arrogant and is poor and uneducated. Host community members thought cholera more commonly affected IDPs, while IDPs felt that they often had to behave more hygienically in order to rise above their circumstances and were therefore less likely to get cholera than the host community.
Implications for practitioners – DRC
• Knowledge: Almost everyone understood the association between handwashing and disease transmission. This means that we can stop educating people about disease transmission as part of programs.
• Behavioural settings: Creating dedicated places for handwashing would help to reposition handwashing as a norm and act as a cue or reminder to prompt behaviour. Prior programs that have attempted to do this have installed facilities that are not considered pleasant to use and which break easily. New initiatives should incentivise family units or compounds to design and build their own facilities that are appealing and affordable. Doing these initiatives at the compound level could work well in this context since neighbours are already reliant on each other for many aspects of their daily lives. This would enable families to pool their resources so that they are able to purchase soap for handwashing. A collective commitment to handwashing among the compound members might make handwashing more social judged and therefore adhered to. This may also enable soap and water to be kept at the handwashing facilities.
• Products: There is a need to change perceptions towards soap. This may require organisations to reduce the extent to which they promote handwashing with ash. It will also require hygiene promotion activities that highlight the non-health benefits of soap, such as how nice hands smell afterwards or how soft they feel. This should be done through experiential learning (e.g. people trying different soap products and seeing how they smell). There may also be opportunities to work with women’s groups to rebrand/decorate locally produced soaps to make them more appealing.
• Supporting cholera cases upon discharge: Stronger efforts should be made to map where cholera cases reside and to support patients upon discharge. This will be critical for reducing transmission within the household and among neighbouring households. Tailored hygiene promotion and hygiene kits should be provided to families with a cholera case and their neighbours. Ideally cholera cases should receive hygiene provisions (e.g soap) sufficient for the first three months after their discharge (the period when they are still able to transmit the disease). The provision of hygiene products for this period should be staged. With some given immediately and further provisions given once the family has built a handwashing facility, for example.
• Shifting community perceptions towards cholera: Cholera is understood as a disease but its increasing familiarity is breeding complacency. Rather than continuing to tell people about the health risks of cholera it may be more effective to humanise the disease and emphasise other types of impacts that people are currently unaware of – such as the impact of cholera on household economies and on a person’s social relationships. It is important that this be done in a manner which is not just fearmongering but rather helps people to see a now familiar disease in a new light. One way of doing it would be to film short videos with people who have had cholera and get them to describe their personal experiences. These could then be taken house to house when doing hygiene promotion and shown on tablets/mobile devices.
• Motives: Disgust is currently the primary motivator of handwashing but could still be heightened by implementing activities like Glow Germs (www.glogerm.com). Motives that have been previously used to promote handwashing behaviour such as nurture and affiliation are likely to be less effective in this context than the motives of comfort and attract. One way that this could be done is by creating a picture or video-based narrative that links handwashing with romance and beauty or positions it as a way of feeling momentarily more comfortable despite difficult circumstances.
• Keeping a broad view: People in this context are under a lot of psychological and economic strain. Those delivering hygiene programs need to be mindful of the much bigger issues that people are facing and ideally connect people with other development initiatives which try to address these issues.
Barrier Analysis – DRC
The qualitative work was complemented with a Barrier Analysis (BA) Survey. Some general reflections on this method – DRC:
• This method works very well when complemented with qualitative research. It was able to confirm some of the qualitative insights (eg. hunger and stress making people less able to practice handwashing). The insights from the Barrier Analysis can be interpreted more soundly by setting them against the broader qualitative dataset.
• When doing the Barrier Analysis in this setting we had tried to sample every fifth house (although random selection is not a requirement of BA) which has a child under the age of 5.
• Although this was done in order to get a diverse sample and create a fair way of selecting participants from among a broader population, it was actually perceived as unfair by many people in the camps and communities. In humanitarian response it is common for everyone to receive interventions equally so those houses that did not participate perceived that they may be missing out on something (even if this was not the case).
• To be done effectively Barrier Analysis requires close supervision and diligent data collectors. Staff need to treat every interview with equal care and precision. The repetitiveness of the process can easily lead to data collectors cutting corners by rushing through the interview without sufficient probing or reflection or changing the way questions are asked.
• In DRC and in the previous survey we conducted in Iraq our translators struggled to come up with a local term for ‘approve’ and ‘disapprove’ as it is used in the social norms questions. The terms chosen ended up being more serious in nature and more about bearing witness to the behaviour.
• Often Barrier Analyses generate results that are inconsistent (e.g. responses to different questions contradict each other directly) or that don’t really make sense behaviourally (e.g. we would expect that non-doers were more aware of cultural taboos discouraging handwashing and less aware of community rules that encourage hygiene). The tendency is to disregard such results but this surely calls into question the validity of the other results.
• The Barrier Analysis covers a lot of determinants in a short period of time through quite focused questions. However, such a format may not provide an appropriate setting for participants to actually answer the questions being asked. For example, if a stranger (the data collector) asks a set of rapid questions and then asks about cultural taboos, participants may be likely give a socially desirable response since answering honestly may not align with the format.
• The analysis process for BA surveys is highly subjective but this is rarely acknowledged within the method. As with any analysis of qualitative data, the number of categories and types of categories created will shape the results of the data substantially.
At the end of the field visit the research team held a dissemination meeting to share the results with key humanitarian actors and the government. The meeting was attended by 71 participants from 31 different NGOs or government departments. The meeting consisted of an introduction to behaviour change and behavioural determinants; a ‘methods marketplace’ where people had the change to wander around the room and interact with posters, tools and photos from each method; a presentation on the qualitative results, a presentation on the Barrier Analysis results; and closing remarks from the Deputy Governor of Dohuk. At the beginning of the session participants were asked to write down on a piece of paper the main reasons people in camps in communities do not always wash their hands and suggest a solution. The most common problems cited were a lack of soap, water and appropriate WASH facilities; a lack of bio-medical knowledge; a belief that handwashing was not a part of their prior culture or habits; and that as part of the psychological impact of displacement, people show signs of depression that translates into them being too bored, forgetful, and lazy to wash their hands. The predominant solutions related to increased education about handwashing and the provision of hygiene kits.
Key stakeholders were invited to dissemination meetings in Goma and in Kinshasa in March/April 2018. The Goma dissemination workshop was attended by 45 people from 26 different international NGOs, local NGOs, government agencies and UN agencies. The entire workshop was presented by the three Research Assistants Anna Mutula Christine, François Kawalina Mazimwe and Modeste Munganga Buroko. The workshop in Kinshasa was attended by 43 people from 26 different International NGOs, local NGOs, UN agencies, government agencies and donor agencies. It followed the same format as the one in Goma and was also lead by the three Research Assistants.
About this project
“This project is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Action Contre La Faim (ACF), The London School of Hygiene and Tropical Medicine (LSHTM), and CAWST (Centre for Affordable Water and Sanitation Technology) and do not necessarily reflect the views of USAID or the United States Government.“