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Objectives This multicountry analysis aimed to assess the prevalence of key hygiene prevention behaviours and their determinants, associated with international non-governmental organisation (WaterAid) hygiene behaviour change programmes for COVID-19 prevention. The goal of this analysis is to inform future outbreak preparedness and pandemic response in low and middle-income countries.Design Cross-sectional study.Setting Households in seven countries where WaterAid implemented a first-phase COVID-19 response programme in 2020 (Ethiopia, Ghana, Nepal, Nigeria, Rwanda, Tanzania and Zambia).Participants 3033 adults (1469 men and 1564 women, alternately sampled from one household to the next to maintain gender balance) in specific programme areas (211 villages) surveyed between October and November 2020.Primary outcome measures Self-reported primary outcomes were: a composite measure of HWWS for prevention of respiratory infection/COVID-19 (total of 5 key moments); respondent increased HWWS behaviour after the COVID-19 pandemic; respondent always wears a mask in public spaces; respondent always practices physical distancing in public spaces.Results Most respondents (80%) reported increasing their handwashing behaviour after the pandemic, but practice of HWWS at COVID-19-specific prevention moments was low. Mask wearing (58%) and physical distancing (29%) varied substantially between countries. Determinants of key behaviours were identified, including age and socioeconomic status, perceived norms, self-regulation and the motive of protecting others. Incidence rate ratios or odds ratios and 95% CIs for a range of psychosocial determinants for each of the four primary outcomes are reported.Conclusions These findings highlight that leveraging behaviour-specific emotional drivers and norms, reducing common barriers and promoting targeted messages about specific behaviours and actions individuals can take to reduce risk are necessary to support large-scale behaviour change. Learning from the COVID-19 response to more effectively integrate novel behaviours into existing health promotion will be vital for disease prevention and outbreak resilience.

Abstract Background Handwashing with soap is critical for the prevention of diarrhoeal diseases and outbreak related diseases, including interrupting the transmission of COVID-19. People living in large displacement settings are particularly vulnerable to such outbreaks, however, practicing handwashing is typically challenging in these contexts. Methods We conducted a qualitative assessment of the implementation of a combined intervention to facilitate handwashing behaviour in displacement camps and in surrounding communities in Bangladesh, Ethiopia and the Democratic Republic of Congo during the COVID-19 pandemic. The intervention comprised a ‘hardware’ infrastructural component (provision of the Oxfam Handwashing Station) and a ‘software’ hygiene promotion package (Mum’s Magic Hands). We used programmatic logbooks, interviews with implementation staff and focus group discussions with crisis-affected populations to assess the use, feasibility and acceptability of the intervention. Results Both components of the intervention were viewed as novel and appealing by implementing staff and crisis-affected populations across the study sites. The acceptability of the handwashing station could be improved by redesigning the tap and legs, exploring local supply chain options, and by providing a greater number of facilities. The implementation of the hygiene promotion package varied substantially by country making it challenging to evaluate and compare. A greater focus on community engagement could address misconceptions, barriers related to the intuitiveness of the handwashing station design, and willingness to participate in the hygiene promotion component. Conclusions The combination of a ‘hardware’ and ‘software’ intervention in these settings appeared to facilitate both access and use of handwashing facilities. The acceptability of the combined intervention was partially because a great deal of effort had been put into their design. However, even when delivering well-designed interventions, there are many contextual aspects that need to be considered, as well as unintended consequences which can affect the acceptability of an intervention.

Abstract Background Hygiene behaviour change programmes are complex to design. These challenges are heightened during crises when humanitarian responders are under pressure to implement programmes rapidly despite having limited information about the local situation, behaviours and opinions—all of which may also be rapidly evolving. Methods We conducted in-depth interviews with 36 humanitarian staff involved in hygiene programme design in two crisis-affected settings—one a conflict affected setting (Iraq) and the other amid a cholera outbreak (Democratic Republic of the Congo). Interviews explored decision-making in each phase of the humanitarian project cycle and were thematically analysed. Results Participants considered the design and implementation of hygiene programmes in crises to be sub-optimal. Humanitarians faced sector-specific challenges as well as more general constraints associated with operating within the humanitarian system. Programme-design decisions were made naturalistically and relied heavily on the intuitions and assumptions of senior staff. National organisations were often side-lined from programme design processes despite being in a better position to gather situational data. Consequently, programme design and decision-making processes adopted by humanitarians were similar across the two settings studied and led to similar types of hygiene promotion activities being delivered. Conclusion Hygiene programming in crises-affected settings could be strengthened by initiatives targeted at supporting humanitarian staff during the pre-implementation programme design phase. This may include rapid assessment tools to better understand behavioural determinants in crisis-affected contexts; the use of a theory of change to inform the selection of programme activities; and funding mechanisms which encourage equitable partnerships, phased programming, regular adaptation and have programmatic components targeted at sustainability and sector capacity building. Initiatives aimed at sector reform should be cognisant of inter and intra-organisational dynamics, the ways that expertise is created and valued by the sector, and humanitarian habits and norms that arise in response to system constraints and pressures. These micro-organisational processes affect macro-level outcomes related to programme quality and acceptability and determine or limit the roles of national actors in programme design processes.

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 ).

Abstract Background Hygiene promotion is a cornerstone of humanitarian response during infectious disease outbreaks. Despite this, we know little about how humanitarian organisations design, deliver or monitor hygiene programmes, or about what works to change hygiene behaviours in outbreak settings. This study describes humanitarian perspectives on changing behaviours in crises, through a case study of hygiene promotion during the 2014–2016 Liberian Ebola outbreak. Our aim was to aid better understanding of decision making in high-stress situations where there is little precedent or evidence, and to prompt reflection within the sector around how to improve and support this. Methods We conducted in-depth, semi-structured interviews with fourteen purposively-sampled individuals (key informants) from international organisations involved in hygiene behaviour change during the outbreak. Through thematic analysis we identified the decisions that were made and processes that were followed to design, deliver and monitor interventions. We compared our findings with theory-driven processes used to design behaviour change interventions in non-outbreak situations. Results Humanitarians predominantly focussed on providing hygiene products (e.g. buckets, soap, gloves) and delivering messages through posters, radio and community meetings. They faced challenges in defining which hygiene behaviours to promote. Assessments focused on understanding infrastructural needs, but omitted systematic assessments of hygiene behaviours or their determinants. Humanitarians assumed that fear and disease awareness would be the most powerful motivators for behaviour change. They thought that behaviour change techniques used in non-emergency settings were too ‘experimental’, and were beyond the skillset of most humanitarian actors. Monitoring focussed on inputs and outputs rather than behavioural impact. Conclusions The experiences of humanitarians allowed us to identify areas that could be strengthened when designing hygiene programmes in future outbreaks. Specifically, we identified a need for rapid research methods to explore behavioural determinants; increased skills training for frontline staff, and increased operational research to explore behaviour change strategies that are suited to outbreak situations.

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.

BackgroundIncontinence is a complex health and social issue, which involves the involuntary loss of urine or faeces or both. Individuals with disabilities are particularly vulnerable to incontinence. The management of incontinence has largely been overlooked in low and middle-income settings (LMICs). This study aimed to explore the incontinence management strategies employed by disabled people with severe incontinence and their caregivers in Sindh Province, Pakistan.MethodsIncontinence management was explored through in-depth interviews with people with incontinence (PWI) and their caregivers, photovoice, and a market survey and product attribute assessment. Data was analysed thematically through inductive coding and evaluated against existing disability and caregiver frameworks.ResultsIncontinence management affected all aspects of daily life for PWI and caregivers. Effective management of incontinence was prioritised because caregivers viewed it to be part of their familial duty and a requirement for the household to remain pure in the eyes of God. Coping strategies included strict adherence to routines, reducing food and drink intake, creative uses of locally available natural resources, and a heavy reliance on soap and water for maintaining hygiene. Products such as adult diapers were largely unavailable, costly and were not deemed suitable for regular use. There were no social or medical interventions in the region to support incontinence management. The main impacts of incontinence on the household were social isolation, stigma, role shifts within the family, the development of physical ailments among caregivers, and decreased income.ConclusionThe complex health, psychological, social, economic, and cultural impacts of incontinence are exacerbated in LMICs due a lack of recognition of the condition, the absence of social or medical interventions and limited access to basic WASH infrastructure, and assistive devices or products. Appropriate solutions need to be developed in partnership with PWI and caregivers and need to be contextualised, affordable and sustainable.

This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different post-conflict settings in Northern Iraq–a long-term displacement camp, a short-term displacement camp, and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and, of these, 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical, psychological, social and economic circumstances of displaced populations. Future hygiene programmes in post-conflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency, build on adaptive norms, create an enabling environment and which are integrated with other aspects of humanitarian response.

Introduction: The Carer Support Unit (CSU) of the Central Coast Local Health District (CCLHD), NSW, Australia, developed, trialled and implemented a Carer Readiness Tool (CRT) to help carers gauge their readiness to care at home, highlight to hospital staff areas for additional support for carers, and provide evidence of carer engagement in discharge planning. Description: A rigorous co-design process was followed with carer consultation at key milestones in development of the CRT. The tool was piloted in two cancer/chronic renal disease inpatient units commencing November 2019. Discussion: The CRT was well-received by carers who appreciated the opportunity to complete the tool in their own time, not in front of the patient. Positive feedback was received from clinicians, including the breadth of the CRT’s content which contributed to better discharge planning. The need to manually incorporate a hard copy form into the electronic medical record is a limitation of the CRT. Conclusion: The CRT is context-specific and fit for purpose. During the development of the CRT, the project team focused on the face validity and usefulness of the tool. The next stage of the project will be formal evaluation of the tool to measure its impact.

While large-scale changes in population behaviour are required to reduce the transmission of the severe acute respiratory syndrome coronavirus 2 virus, the emergency context is not conducive to the sort of careful communications planning that would normally be required to meet such a task. Rapid strategic communications planning in a pandemic by governments is, however, possible and necessary. Steps include setting up a dedicated communications task force, mobilising partners and resources, developing a creative brief and theory of change and overseeing the creation, testing, roll out and revision of content. In this short guide, we argue that a minimum of strategic planning can be undertaken rapidly, and that good use can be made of simple principles of behaviour change, even during pandemics. Our aim here is to provide a blueprint that governments and their partners, especially in low-income settings, can follow to design, coordinate and resource national communications efforts to combat the COVID-19 pandemic immediately and for the longer term.

BACKGROUND:Diarrhoea is one of the most common causes of mortality and morbidity among populations displaced due to conflict. Handwashing with soap has the potential to halve the burden of diarrhoeal diseases in crisis contexts. This study aimed to identify which determinants drive handwashing behaviour in post-conflict, displacement camps. METHODS:This study was conducted in two camps for internally displaced people in the Kurdistan Region of Iraq. A Barrier Analysis questionnaire was used for assessing the determinants of hand washing behaviour. Participants were screened and classified as either 'doers' (those who wash their hands with soap at critical times) or 'non-doers' (those who do not wash their hands with soap at critical times). Forty-five doers and non-doers were randomly selected from each camp and asked about behavioural determinants. The Barrier Analysis standard tabulation sheet was used for the analysis. RESULTS:No differences were observed between doers and non-doers in relation to self-efficacy, action efficacy, the difficulties and benefits of handwashing, and levels of access to soap and water. In the first of the two camps, non-doers found it harder to remember to wash their hands (P = 0.045), had lower perceived vulnerability to diarrhoea (P = 0.037), lower perceived severity of diarrhoea (P = 0.020) and were aware of 'policies' which supported handwashing with soap (P = 0.037). In the second camp non-doers had lower perceived vulnerability to diarrhoea (P = 0.017). CONCLUSIONS:In these camp settings handwashing behaviour, and the factors that determine it, was relatively homogenous because of the homogeneity of the settings and the socio-demographics of population. Handwashing programmes should seek to improve the convenience and quality of handwashing facilities, create cues to trigger handwashing behaviour and increase perceived risk. We identify several ways to improve the validity of the Barrier Analysis method such as using it in combination with other more holistic qualitative tools and revising the statistical analysis.

BackgroundTrachoma is the leading infectious cause of blindness. However, little is known about the behavioural and environmental determinants of transmission of the causative organism, Chlamydia trachomatis. We conducted formative research in a trachoma hyper-endemic area of Ethiopia to explore the behaviours which are likely to contribute to trachoma transmission and map their determinants.Methodology/principal findingsData on water use, hygiene, defecation, and sleeping arrangements were collected from five communities during the dry and rainy seasons in 2016. Data collection involved direct observation in households (n = 20), interviews with caregivers (n = 20) and focus group discussions (n = 11). Although several behaviours that likely contribute to trachoma transmission were identified, no single behaviour stood out as the dominant contributor. Hygiene practices reflected high levels of poverty and water scarcity. Face washing and soap use varied within and between households, and were associated with other factors such as school attendance. Children's faces were rarely wiped to remove nasal or ocular discharge, which was not perceived to be socially undesirable. Bathing and laundry were performed infrequently due to the amount of time and water required. Open defecation was a normative practice, particularly for young children. Latrines, when present, were poorly constructed, maintained and used. Young children and parents slept closely together and shared bedding that was infrequently washed.Conclusions/significanceExisting norms and enabling factors in this context favour the development of interventions to improve facial cleanliness as more feasible than those that reduce unsafe faeces disposal. Interventions to increase the frequency of bathing and laundry may also be infeasible unless water availability within the home is improved.

BackgroundThe critical importance of safe and affordable access to water, sanitation and hygiene (WASH) is highlighted in Goal 6 of the Sustainable Development Goals, which seeks to achieve universal and equitable access for all by 2030. However, people with disabilities-who comprise 15% of the global population-frequently face difficulties meeting their WASH needs. Unmet WASH needs amongst people with disabilities may not be captured through current approaches to tracking progress towards Goal 6, which focus on household- rather than individual-level access.ObjectiveTo evaluate access to safe water, sanitation and hygiene (WASH), at the individual- and household-level, amongst people with disabilities in the Tanahun district of Nepal.MethodsA population-based survey of disability was conducted from August-October 2016 to evaluate access to improved water and sanitation facilities between households with members with disabilities (n = 198) and those without (n = 1,265) in the Tanahun district of Nepal. A nested case-control then compared individual-level access between cases aged 15 and above with disabilities (n = 192) and age-sex-location matched controls without disabilities (n = 189), using the newly developed 21-item "Quality of WASH Access" questionnaire. Multivariate regression was used to compare household- and individual-level indicators between people and households with and without disabilities. In-depth interviews with 18 people with disabilities and their caregivers was conducted to assess the acceptability and appropriateness of the "Quality of WASH Access" questionnaire.FindingsThere were no significant differences between households with and without members with disabilities in access to an improved sanitation facility or water source. However, at the individual-level, people with disabilities experienced significantly greater difficulties accessing water, sanitation and hygiene compared to people without disabilities (pConclusionPeople with disabilities face substantial challenges to meeting their WASH needs, particularly in using services autonomously, consistently, hygienically, with dignity and privacy, and without pain or fear of abuse. These challenges are not captured through household-level data, and so individual-level WASH access are needed to monitor progress towards universal WASH access. The Quality of WASH Access questionnaire may provide a useful data collection tool.

BackgroundDiarrhoeal diseases are a major contributor to morbidity and mortality in humanitarian crises. Handwashing with soap may reduce diarrhoea by up to 47%, however, the circumstances associated with displacement make it challenging for crisis-affected populations to be able to wash their hands with soap. The Supertowel is an alternative hand-cleaning product, proven to be as efficacious as handwashing with soap. The Supertowel is a micro-fibre towel with an anti-microbial treatment. When dipped in water it is capable of removing and killing pathogens from hands. This study aims to assess whether the Supertowel could be an acceptable and feasible product for crisis-affected populations.MethodsThe study took place in an Eritrean refugee camp located in Tigray state in Ethiopia. We used a mix of qualitative methods to understand use and acceptability, including baseline observations (n = 13), behaviour trials involving interviews at three time points (n = 19) and focus group discussions (n = 3). We thematically analysed data from interviews and discussions.ResultsParticipants indicated that the Supertowel was convenient, easy to use and saved them water and money. All households participating in the behaviour trials had at least one Supertowel in use at the end of the trials (follow-up visit two). In discussions participants reported that the Supertowel was more desirable than comparable hand cleaning products. In interviews, trial participants explained that the product enabled them to clean their hands at times when they might not normally bother. The research also identified some issues with the smell of the Supertowel and its intuitive use.ConclusionsThe Supertowel was found to be an acceptable and useful hand-cleaning product that could complement soap use in crisis contexts. This pilot study also identified areas of future research including the need to compare different distribution models for the Supertowel (distribution in hygiene kits compared to distribution with an accompanying communication package) and to evaluate its use at scale over a longer time period.

OBJECTIVE:To assess the Water, Sanitation and Hygiene (WASH) access and appropriateness of people with disabilities compared to those without, in Guatemala. METHODS:A case-control study was conducted, nested within a national survey. The study included 707 people with disabilities, and 465 age- and sex-matched controls without disabilities. Participants reported on WASH access at the household and individual level. A sub-set of 121 cases and 104 controls completed a newly designed, in-depth WASH questionnaire. RESULTS:Households including people with disabilities were more likely to use an improved sanitation facility compared to control households (age-sex-adjusted OR: 1.7, 95% CI 1.3-2.5), but otherwise there were no differences in WASH access at the household level. At the individual level, people with disabilities reported greater difficulties in relation to sanitation (mean score 26.2, SD 26.5) and hygiene access and quality (mean 30.7, SD 24.2) compared to those without disabilities (15.5, 21.7, p

Globally, millions of people lack access to improved water, sanitation and hygiene (WASH). Disabled people, disadvantaged both physically and socially, are likely to be among those facing the greatest inequities in WASH access. This study explores the WASH priorities of disabled people and uses the social model of disability and the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to look at the relationships between impairments, contextual factors and barriers to WASH access. 36 disabled people and 15 carers from urban and rural Malawi were purposively selected through key informants. The study employed a range of qualitative methods including interviews, emotion mapping, free-listing of priorities, ranking, photo voice, observation and WASH demonstrations. A thematic analysis was conducted using nVivo 10. WASH access affected all participants and comprised almost a third of the challenges of daily living identified by disabled people. Participants reported 50 barriers which related to water and sanitation access, personal and hand hygiene, social attitudes and participation in WASH programs. No two individuals reported facing the same set of barriers. This study found that being female, being from an urban area and having limited wealth and education were likely to increase the number and intensity of the barriers faced by an individual. The social model proved useful for classifying the majority of barriers. However, this model was weaker when applied to individuals who were more seriously disabled by their body function. This study found that body function limitations such as incontinence, pain and an inability to communicate WASH needs are in and of themselves significant barriers to adequate WASH access. Understanding these access barriers is important for the WASH sector at a time when there is a global push for equitable access.

The blanket bog ecosystems of the UK uplands fulfil important biodiversity and ecosystem services at multiple spatial scales. In response to perceived negative effects of burning to control heather growth on blanket bog, regulations on vegetation management now restrict this practice as part of the UK’s wider commitment to reducing carbon emissions. Instead, there has been a significant shift towards cutting as an alternative heather management tool, despite a notable lack of research on its effects on blanket bog. A key component of blanket bog ecosystems in the UK uplands is the moss layer, in which Sphagnum mosses play a particularly significant role. To investigate the immediate effects of heather cutting on the structure and extent of the moss layer, measurements of moss depth and cover at the end of the cutting season were taken from cut and uncut areas of two managed blanket bog sites in northern England. Measurements of moss depth were used to generate an index of moss microtopography. Cutting resulted in significant reductions of moss depth, heterogeneity of moss hummock microtopography, and extent of pleurocarpous moss, but there was no change in cover of Sphagnum or acrocarpous mosses. Further research is needed to understand the effects of cutting, particularly in the longer term, in terms of cutting height, type of machinery used, whether brash is removed, and repeat cut interval. This research will inform evidence-based management of blanket bog habitats.

Burning of ericaceous vegetation on moorland in the United Kingdom is a routine part of management for red grouse (Lagopus lagopus scotica) but its contribution to peatland degradation and loss of key ecosystem services is widely debated. Studies in the North Pennines, northern England, have shown that regular fires at approximately ten-year intervals can benefit Sphagnum mosses and cotton grass (Eriophorum) cover at the expense of ling heather (Calluna vulgaris). We repeated an assessment from a Pennine study of post-burning vegetation succession at a moor in south-west Scotland also managed for grouse. Here, GPS-mapped fires from 2009 to 14 were visited in 2019 to measure the vegetation response and compare it with unburned control plots. Heather cover, vegetation height and biomass increased linearly over time since burning, whereas cotton grass decreased during the first eight years. Sphagnum cover in plots burnt eight to ten years earlier averaged five times higher than that in the no-burn control plots and was positively correlated with peat depth. These results support earlier studies in northern England, showing that prescribed burning at regular intervals can increase Sphagnum cover by reducing heather cover and canopy vegetation biomass. We discuss the repercussions of this for management of blanket peat habitat, including reducing wildfire risk across UK moorlands.