Programmatic implications for promotion of handwashing behavior in an internally displaced persons camp in North Kivu, Democratic Republic of Congo

Abstract

BackgroundDiarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situations, little is known about determinants of handwashing behavior in emergency settings.MethodsWe conducted a qualitative investigation from June to August 2015 in a camp for internally displaced persons with a population of 6360 in the war-torn eastern region of the Democratic Republic of Congo. We held key informant interviews with 9 non-governmental organizations and camp officials, in-depth interviews and rating exercises with 18 mothers of children < 5 years, and discussions with 4 groups of camp residents and hygiene promoters to identify motivators and barriers to handwashing.ResultsAt the time of the study, hygiene promotion activities lacked adequate resources, cultural acceptability, innovation, and adaptation for sustained behavioral change. Lack of ongoing provision of hygiene materials was a major barrier to handwashing behavior. When hygiene materials were available, camp residents reported that the primary motivator to handwashing was to prevent illness, particularly diarrheal disease, with many mentioning an increased need to wash hands during diarrhea outbreaks. Emotionally- and socially-related motivators such as “maintaining a good image” and social pressure to follow recommended camp hygiene practices were also reported to motivate handwashing with soap. Residents who engaged in day labor outside the camp had limited exposure to hygiene messages and handwashing facilities. Interviewees indicated that the harsh living conditions forced residents to prioritize obtaining basic survival needs over good hygiene.ConclusionsHygiene promotion in camp settings must involve preparedness of adequate resources and supplies and ongoing provision of hygiene materials so that vulnerable populations affected by emergencies can apply good hygiene behaviors for the duration of the camp’s existence. Compared to non-emergency contexts, illness-based messages may be more effective in emergency settings where disease poses a current and ongoing threat. However, failure to use emotive and social drivers that motivate handwashing may present missed opportunities to improve handwashing in camps.

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“…Previously, studies done on handwashing in emergencies suggest that people likely adhere to their pre-emergency standards of hygiene. 29 Humans are creatures of habit, and this makes newly acquired behaviours fragile.…”

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“…19 A hand hygiene study with displaced adults in the Democratic Republic of Congo highlighted the role of emotional and social motivators and a need for innovation. 20 Physical distancing is not feasible in crowded settlements, 21 yet limited research has assessed strategies to promote alternatives such as household or community shielding. 3 22 Our study applies behavioural science to mobile health (mHealth) to increase COVID-19 preventive practice uptake with urban refugee youth.…”

A pilot study of the effect of improved hygiene kits on handwashing with soap among internally displaced persons in Ethiopia.

“…The kits aim to reduce the risk of disease transmission by encouraging increased levels of hygiene at the household level, but distribution of hygiene items has achieved mixed results in crisis settings (8,(12)(13)(14)(15). After increased soap provision in a South Sudanese refugee camp, handwashing with water only was more commonly observed (< 70%) than handwashing with soap (< 20%), although over 95% of participants reported that soap was available and more than 84% reported exposure to handwashing promotion where messages of the importance of soap had been shared (8).…”

“…After increased soap provision in a South Sudanese refugee camp, handwashing with water only was more commonly observed (< 70%) than handwashing with soap (< 20%), although over 95% of participants reported that soap was available and more than 84% reported exposure to handwashing promotion where messages of the importance of soap had been shared (8). In refugee camps in Sub-Saharan Africa and South-East Asia, handwashing facilities distributed to households or installed by camp management were found to be missing or not working (13)(14)(15). Provision of soap and handwashing facilities are only effective in protecting against disease if used as intended.…”