Hygiene behaviour and hygiene behaviour change during humanitarian crises

More than any other public health intervention, handwashing with soap can reduce the burden of faecal-oral diseases. Over the last decade substantial research and programmatic investment have gone into better understanding the determinants of people's handwashing behaviour. However, this research base is derived almost entirely from work conducted in stable settings. When a humanitarian crisis occurs, whether it be a disease outbreak, a disaster or a conflict, the social and physical environments of the affected population are disrupted. At the same time, disease risk related to faecal-oral pathogens substantially increases. Given that we currently lack an in-depth understanding of the factors that drive behaviour in crises, hygiene programmes in these settings typically rely on a narrow set of 'traditional' interventions such as health education and the distribution of hygiene kits. Although knowledge about handwashing and enabling products are likely to be important, these interventions alone have been shown to be insufficient to lead to meaningful and sustained changes in behaviour. Recent systematic reviews and research agenda setting activities within the humanitarian sector have suggested that research on hand hygiene behaviour and improved hygiene programme design in emergencies should prioritised. This thesis is grounded in a pragmatic epistemology and uses a mix of methods drawn from the disciples of cultural anthropology and behavioural science. It aims to better understand what influences hygiene behaviour during crises and outbreaks and identify opportunities for effective hygiene behaviour change in these settings. The thesis includes five manuscripts. The first is a literature review which aims to identify and categorise the determinants of handwashing behaviour in stable settings, crises and outbreaks and to appraise the quality of this evidence. The second assesses the strengths and limitations of a survey-based tool which is commonly used in humanitarian crises to understand behavioural determinants. The third and fourth paper are qualitative case studies set in Iraq and the Democratic Republic of the Congo. Both explore how the determinants of handwashing behaviour are shaped by different types of crises. The thesis concludes with a paper about experiences and challenges faced by humanitarians when designing hygiene programmes in emergencies. Prior research on behavioural determinants was found to be poor quality and limited by methodological challenges and inconsistent definitions of determinants. The literature review was unable to draw conclusions about the determinants of hygiene behaviour in crises or outbreaks due to a lack of evidence. Current approaches to assessing determinants in crises were feasible to conduct but were methodologically limited and unable to fully account for contextual factors and the impact of the crisis on behaviour. The qualitative case studies indicated that the relative importance of certain determinants is likely to vary during crises and outbreaks. The characteristics that appear to affect the variation of behavioural determinants include the type of crisis; the phase of the crisis or outbreak; the physical and social context; and the broader consequences of the crisis or outbreak on the lives of the affected population. The determinants that seem to be most influential in driving hygiene behaviour during crises and outbreaks included risk perceptions; the prioritisation of time and resources, daily routines; and factors within the behavioural settings where handwashing takes place (such as access to handwashing facilities, water and soap). Interviews with humanitarians indicated that the constraints humanitarians faced when designing hygiene programmes, and the way they made decisions, were remarkably similar across contexts, leading to programming that was also relatively de-contextualised. Hygiene programme design processes were considered sub-optimal, but humanitarians struggled to implement the more ideal principles and processes that they aspired to due to time pressures; financial constraints; limited capacities; the infeasibility of assessment tools; unequal partnerships organisations; and poor sector learning processes. Given these constraints, most programmatic decisions were based on the intuitions and past experiences of managerial staff. The findings presented in this thesis offer opportunities for strengthening the assessment of behavioural determinants and improving hygiene programme design so that it can be done rapidly, while still being contextualised and evidence-based.