In the North East Region of Nigeria, the insurgent activities of Boko Haram have forced 2 million people to flee and become internally displaced, of which about half are children(1). Internally displaced persons (IDPs) are 'persons or groups of people who have been forced or obliged to flee or leave their homes or places of habitual residence, in particular as a result of, or in order to avoid the effects of armed conflicts, situations of generalised violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognised state border'(2).
Internal displacement has a significant impact on the health and well-being of the affected populations (3–7), especially children. Diseases such as respiratory infections, diarrhoea, scabies, malaria and measles are common among displaced children (8–10). For instance, a study of Uganda IDP camps revealed that the most prevalent symptoms among children in the IDP camps were fever, cough and diarrhoea (3). These are mainly caused by inadequate sanitation, poor hygiene and inadequate water supplies (4, 8, 11–13). As a result, adequate sanitation, water supplies and good hygiene are essential determinants for the survival of displaced populations (6, 13).
The Hygiene Improvement Framework (HIF) postulates that a comprehensive approach that entails: (i) improving access to water and sanitation (ii) promotion of hygiene and (iii) strengthening an enabling environment are all essential to promoting hygienic household behaviors. These subsequently reduces the transmission of diseases and promotes better health outcomes. Furthermore, researchers have argued that water supply, sanitation and hygiene promotion interventions should be implemented as a package and should not be disaggregated (6, 14, 15).
In line with the Hygiene Improvement Framework (HIF), humanitarian programs carried out by agencies use Water, Sanitation, and Hygiene interventions (WASH), these kinds of interventions are used to mitigate disease risk and improve health in emergency settings (12).WASH interventions usually consist of a combination of improvements to water supply, sanitation and hygiene promotion in order to reduce the transmission of infectious diseases through the promotion of good hygiene practices, the provision of safe drinking water and the reduction of environmental health risks (6, 11, 12). WASH package interventions are usually carried out concurrently and usually consist of water point rehabilitation, hygiene kit distributions and hygiene promotion (16).
In non-emergency settings, WASH package interventions – as well as the general Hygiene Improvement Framework (HIF) on which they are based – have been found to improve hygiene behaviours and subsequently improve health. For instance, adequate water supply was reported to improve household hygiene behaviour ( handwashing, bathing, food washing, and household cleaning) in a study conducted in Bangladesh (17). Likewise, in the Democratic Republic of Congo, there was an increase in handwashing practices, a hygienic display of market goods and a 50% reduction in diarrhoea prevalence among children of market sellers after water-point units were used to teach the community members about hygiene as the hygiene promotion component of an intervention. The intervention had the construction of water and sanitation facilities as the water and sanitation component. Also, the maintenance of the facilities was implemented by private business as the enabling environment component (18).
Examples of activities in the HIF components are: (i) improved access to water and sanitation, which could be the provision of soaps, safe water containers, and effective water treatments. (ii) Promotion of hygiene, which entails communication, social mobilisation and social marketing and (iii) strengthening of enabling environment which could be community involvement, institutional strengthening, financing and cost recovery activities, and policy improvement.
However, evidence on the effect of a comprehensive WASH package intervention on hygiene behaviour, and the subsequent effect on health outcomes in an emergency setting are scanty and inconclusive. For instance, a study in hurricane-affected communities in the Dominican Republic reported a 16% increase in handwashing practices before eating for children after the implementation of a comprehensive HIF WASH intervention(19). Likewise, a study in a Malawi refugee camp reported that the availability of regular soap within the household reduces the occurrence of diarrhea in the refugee population (20). Whereas a study in a South Sudan refugee camp, after a disease outbreak, reported poor levels of proper handwashing behaviour despite hygiene education and availability of soap and water within the camps(21). Similarly, studies from Kenya, Thailand and Ethiopian refugee camps reported low handwashing behaviour despite hygiene education within the camps(22). With the large number of people who are displaced and are at risk of communicable diseases, more substantial evidence is needed (6, 8, 11, 12, 23–28). Additionally, it has been suggested that evidence on the health outcomes of WASH interventions should distinguish between the type of crisis (either natural disaster or conflict), the type of community (rural or urban), the type of displacement (internally or externally) and children (11, 29).
The objectives of this study are to fill these knowledge gaps by looking at the relationship between (1) a WASH package intervention, (2) socio-demographic characteristics, (3) personal hygiene behaviour (i.e. bathing) and (4) health outcomes (becoming sick and having diarrhea), for children who are internally displaced due to conflict in rural communities. Bathing in this study is the washing of the body with soap for body cleanliness to provide general personal hygiene, comfort and relief (30).We hypothesise that (1) the WASH intervention would improve bathing frequency among children and that (2) Bathing frequency will negatively affect the frequency of sickness and occurrence of diarrhea among the children.