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Background The Wash’Em process was developed to improve the design of handwashing behaviour change programmes in outbreaks and fragile humanitarian settings, ensuring that programmes are able to be designed rapidly while still being contextualised and evidence-based. The approach was widely used during the COVID-19 pandemic to inform prevention programmes. This study aims to compare data emerging from the use of the Wash’Em process during the pandemic, to understand whether commonalities in programming constraints or the determinants of handwashing behaviour existed across countries. Methods We conducted a secondary data analysis of summary data entered into the Wash’Em Programme Designer Software. This summary data was drawn from the use of the Wash’Em Rapid Assessment Tools in 38 settings during the pandemic. Data was verified prior to inclusion; descriptively summarised and then statistical summaries of homogeneity were derived. Results Wash’Em was implemented as intended during the pandemic, typically taking a small number of humanitarian staff less than a week to complete. Most humanitarian actors reported using the programmatic recommendations suggested by the process but did so within relatively short-term and poorly financed prevention programmes. Homogeneity in the responses to the Rapid Assessment Tools was low indicating that the determinants of handwashing behaviour during the pandemic were predominantly shaped by pre-existing factors within the context rather than the nature of the health threat. Conclusion Hygiene programmes during outbreaks should avoid ‘copying and pasting’ interventions from one setting to another and instead make time to holistically understand the behavioural determinants in a specific context and develop programme activities that are designed to address these. Particular attention should be given to factors in the physical and social environment which may enable or constrain handwashing behaviour, pre-existing disease vulnerabilities, and the secondary and non-health impacts of outbreaks. Wash’Em provides one feasible way of contextualising handwashing interventions in outbreak or fragile humanitarians settings.

Background: At the onset of the pandemic in Kenya, a multisector taskforce was set up to coordinate the COVID-19 response. The taskforce identified 7500 COVID-19 transmissions ‘hotspots’ in public spaces across Kenya, coordinated partners and implemented hand hygiene interventions. To complement these efforts, the National Business Compact Coalition procured and distributed 5311 handwashing stations (HWSs); conducted behavior change communications; and provided technical support on operation, maintenance and monitoring to HWSs caretakers across the country. In view of these interventions, it was paramount to assess the functionality, usability and accessibility of the public HWSs in order to improve the operation and maintenance and inform strategies for future roll-out of HWSs in public settings. Methods: This was a mixed-methods observational study conducted in five randomly selected counties in Kenya: Nairobi, Kwale, Embu, Mombasa and Homabay. Quantitative data were collected through spot checks of randomly selected HWSs in these counties, caretaker surveys, user observations and user exit interviews. Qualitative data were collected through key informant interviews, focus group discussions and in-depth interviews. Quantitative data were analyzed using Chi-square tests, or where applicable, Fisher’s exact tests to assess the accessibility, usability and functionality of the HWSs. Qualitative data were analysed thematically and used to support the quantitative findings. Results: A total of 430 HWSs were targeted for this study and 316 (73%) were located and surveyed. The remainder were largely absent because the caretakers were absent or had relocated, or had been stolen, in storage or in the caretakers’ home. Of the located handwashing facilities, 83.9% were functional (meaning the facility had water in it, soap available for use and a functioning tap). A significantly higher proportion of functional handwashing stations were managed by a paid caretaker (95.9%) compared to an unpaid caretaker (78.4%) (P=0.001). Only 35% of HWSs were accessible for a person using a wheelchair, 76.9 accessible for child under 12 years, and 76.3% accessible for older persons, 81.6% of users reported HWSs to be of comfortable height, and about half (49.1%) of the HWSs were set up on uneven and/or muddy ground. Conclusion: This study has demonstrated distribution of public handwashing facilities can have a limited lifespan. HWSs future distributions should prioritise long-term plans for follow-up with caretakers responsible for operation and maintenance of public handwashing stations to provide support and to sustain accountability. It is also imperative to make HWSs accessible for wheelchair users and those less able to walk. Finally, design considerations should be made for comfortable height, placement in stable surfaces, soap placement and drainage of wastewater.

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).

Background Internally displaced persons (IDPs) forced to flee from their homes due to conflict and drought are at particular risk of morbidity and mortality due to diarrhoeal diseases. Regular handwashing with soap could substantially reduce the risk of these infections, but the behaviour is challenging to practice routinely 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 improved kits on handwashing behaviours among IDPs in Moyale, Ethiopia. Methods The pilot study evaluated three interventions separately; liquid soap, a good quality scented bar soap and a mirror as additions to a regular hygiene kit. The kit was distributed to all study groups, with 3 of the study groups receiving one of the interventions each. Three to six weeks after distribution, behaviour change was assessed through structured observations, surveys and focus group discussions. Results Handwashing with soap was rare at key times both in all study groups. In the group that received liquid soap, handwashing with soap was seen at 20% of key times. In the control arm this was 17%, while in the two other intervention arms prevalence was Conclusion This study was to our knowledge the first randomised intervention study on handwashing among IDPs living in a non-camp setting. The study shows that improved kits have potential to make handwashing more desirable and easier to practice, and further research including formative assessments prior to the design of hygiene kits should be conducted to ensure maximal uptake. The challenges of doing research in conflict-affected regions had considerable implications on the design and implementation of this study.Trial registration The trial was registered at www.ClinicalTrials.gov 6 September 2019 (reg no: NCT04078633)

Background Hygiene promotion interventions are likely to be more effective if they target the determinants of handwashing behaviour. Synthesis of the evidence on the determinants of handwashing behaviour is needed to enable practitioners to use evidence in hygiene promotion programming. Purpose To identify, define and categorise the determinants of handwashing behaviour in domestic settings and to appraise the quality of this evidence. Methods We conducted an integrative review, searching three databases for terms related to handwashing and behaviour change determinants. Studies were summarised and their quality assessed against a pre-defined set of criteria for qualitative, quantitative and mixed-method studies. Data on determinants were extracted and classified according to a predefined theoretical taxonomy. The effect of each association between a determinant and handwashing behaviour was summarised and weighted based on the quality of evidence provided. Determinants that were reported more than three times were combined into a meta-association and included in the main analysis. Sub-analyses were done for studies conducted during outbreaks or humanitarian crises. Results Seventy-eight studies met the criteria. Of these, 18% were graded as ‘good quality’ and 497 associations between determinants and handwashing behaviour were extracted. We found that 21% of these associations did not clearly define the determinant and 70% did not use a valid or reliable method for assessing determinants and/or behaviour. Fifty meta-associations were included in the main analysis. The determinants of handwashing that were most commonly reported were knowledge, risk, psychological trade-offs or discounts, characteristic traits (like gender, wealth and education), and infrastructure. There was insufficient data to draw conclusions about the determinants of behaviour in outbreaks or crises. Conclusions This review demonstrates that our understanding of behavioural determinants remains sub-optimal. We found that there are limitations in the way behavioural determinants are conceptualised and measured and that research is biased towards exploring a narrow range of behavioural determinants. Hygiene promotion programmes are likely to be most successful if they use multi-modal approaches, combining infrastructural improvement with ‘soft’ hygiene promotion which addresses a range of determinants rather than just education about disease transmission.