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

Abstract

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.

The determinants of handwashing during the COVID-19 pandemic: A multi-country analysis of data from the Wash’Em process for hygiene programme design

“…Similarly, ndings from the Personal Histories Tool indicated the profound non-health impacts of the pandemic on people's lives, particularly in settings where people were already dealing with co-existing outbreaks and crises. The majority of programmes identi ed major shifts in the way participants perceived their role in the family or community, their agency, and their economic fragility during the pandemic -ndings which are consistent with broader research in LMIC settings [49][50][51][52] but which are rarely considered when designing hygiene prevention programmes [53]. Stigma and isolation were commonly reported among those directly affected by COVID-19.…”

“…The process is based on behavioural theory, literature reviews [25], and research in crisis and outbreak affected settings [26][27][28]. The rst part of the Wash'Em process involves the use of ve rapid assessment tools to understand the determinants of behaviour.…”

How are hygiene programmes designed in crises? Qualitative interviews with humanitarians in the Democratic Republic of the Congo and Iraq

“…Understanding the quality, acceptability and effectiveness of hygiene programmes in emergencies should also foreground the views of crisis-affected populations. While not reported here, we conducted complementary in-depth qualitative research with affected populations in both settings [54,55]. Finally, 75% of our participants were male across the two countries and while this reflected the demographics of the sector, the voices and opinions of female WASH staff are under-represented in this work and merits further exploration.…”

Cholera outbreaks among children in sub-Saharan Africa

“…Improving global access to WASH is a critical step to reducing Africa's cholera burden [22]. In a study conducted in DRC Congo, water scarcity and lack of soaps were major barriers to hand hygiene during cholera outbreaks [23]. Conversely, a study in Nigeria demonstrated that reducing poverty and increasing access to sanitation lessened vulnerability to increased cholera risk caused by extreme events [24 ▪▪ ].…”