The determinants of handwashing during the COVID-19 pandemic: A multi-country analysis of data from the Wash’Em process for hygiene programme design

doi:10.21203/rs.3.rs-2956867/v1

Download PDF

Research Article

The determinants of handwashing during the COVID-19 pandemic: A multi-country analysis of data from the Wash’Em process for hygiene programme design

https://doi.org/10.21203/rs.3.rs-2956867/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

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.

Hand hygiene

outbreaks

behaviour change

behavioural determinants

COVID-19

The COVID-19 pandemic drew attention to inequalities within and between nations which placed certain sub-groups of the population at greater health and socio-economic risks [1, 2]. This was particularly true for populations who were already living in fragile, crisis-affected states or displacement settings [3–5]. Characteristically such settings often have dense housing [6], poorer access to water, sanitation, hygiene (WASH) services [7] and limited access to testing, vaccines and health care [8]. Populations in these settings may also experience heightened rates of pre-existing health conditions (e.g. chronic illness, malnutrition, disability, and mental illness) [9–12] and may be dealing with COVID-19 amid other co-existing outbreaks [13, 14]. Together these factors meant that crisis-affected populations were both at higher risk of exposure to COVID-19 and more likely to develop severe symptoms. Furthermore, adhering to COVID-19 preventative behaviours was often more challenging in these settings due to weak supply systems for preventative products (e.g. masks or soap) and water scarcity. Behaviours such as staying at home and physical distancing came at a much higher socio-economic cost given that crisis-affected populations are more likely to live in poverty or be reliant on informal employment or day-to-day wages [15, 16]. Therefore, COVID-19 response programmes in these fragile settings had to rapidly respond to both the immediate challenges created by the pandemic while also addressing many of these chronic challenges.

Humanitarian actors involved prevention programmes during the pandemic were also faced with a complex set of operational constraints: the urgency to act, limited available capacities and resources, the need to engage populations remotely, and an imperfect state of evidence around the disease, its transmission and behavioural responses [17]. A large proportion of preventative work in these settings focused on improving hand hygiene given that was initially seen as the ‘first line of defence’ against this novel pathogen [18]. As more was learned about COVID-19 transmission, hand hygiene continued to be seen as key for interrupting the spread of COVID-19 [19–21] but was also prioritised because of its demonstrated effect in reducing other faecal-oral diseases common in crisis-affected settings [22–24]. Prior to the pandemic, the London School of Hygiene and Tropical Medicine, Action Contre la Faim and the Centre for Affordable Water and Sanitation Technology (CAWST) and USAID's Bureau for Humanitarian Assistance (BHA) had collaborated to create the Wash’Em process (www.washem.info). Wash’Em is designed to aid humanitarians in the design of rapid, evidence-based and contextualised handwashing programmes in crises or outbreaks. Wash’Em therefore provided an opportunity to overcome some of the challenges of handwashing promotion in fragile settings during the pandemic.

An overview of the Wash’Em process

The process is based on behavioural theory, literature reviews [25], and research in crisis and outbreak affected settings [26–28]. The first part of the Wash'Em process involves the use of five rapid assessment tools to understand the determinants of behaviour. The Rapid Assessments focus on exploring the behavioural determinants which were found to vary most substantially by context, or which are likely to be most useful for informing programme design. These include tools that explore behavioural settings (Handwashing Demonstrations Tool), risk perceptions and disease understandings (Disease Perceptions Tool), motives and aspirations (Motives Tool), how behaviour has changed because of the broader experiences of the crisis (Personal Histories Tool), and ways of selecting delivery channels and engaging with communities (Touchpoints Tool). The Rapid Assessments use qualitative participatory methods that are undertaken either at a household level, through interviews and observations, or within focus group discussions. The guides for each of the 5 tools are included as Supplementary Materials 1–5. The second step of the Wash’Em process is for the data collection team to summarise the data by identifying common patterns in participant responses and circumstances. Staff log into the Wash’Em Programme Designer Software and are prompted to answer multiple-choice questions about their context (e.g. the nature of the crisis or outbreak, characteristics of the population, etc.), and the constraints for programme design (e.g. budget, timelines, safety issues, etc.). They also answer multiple-choice questions relating to the five Rapid Assessments, entering the summary data related to behavioural determinants in their context. The full list of multiple-choice questions is available in Supplementary Material 6. At the end of this process, the software generates programme recommendations. The programme recommendations come from a database of theory-driven or evidence-based handwashing behaviour change activities. Algorithms within the software recommended 5 to 7 activities based on the responses to the questions and what is therefore likely to be effective in the context. Each activity has a 'recipe card' which outlines the materials needed, the time it takes, the cost, and a detailed step-by-step process for implementing it. The full Wash'Em process was launched in March 2020. Initially, humanitarian organisations were discouraged from using the approach face-to-face (as it was intended) due to safety concerns during the pandemic. However, over time, organisations developed safety protocols or remote ways of using Wash’Em to inform their pandemic response [29].

The Wash’Em programme designer software records the data entered by humanitarian users about their context, programming and the determinants of hand hygiene behaviour. This study aims to explore whether there were commonalities in the determinants of hygiene behaviour and the nature of COVID-19 response programmes in fragile settings. The hypothesis underpinning this research was that the unprecedented scale of the pandemic may have led humanitarians to face similar programmatic constraints and crisis-affected populations to encounter similar behavioural challenges. Such insights would be useful to inform policy and programming in these settings during the protracted phase of the COVID-19 pandemic and in future outbreaks.

This study involves the analysis of datasets entered into the Wash’Em Programme Designer Software by organisations involved in COVID-19 response programmes in fragile or crisis-affected low-and middle-income countries (LMICs).

Data sets

The data entered into the Wash’Em Programme Designer Software is a summary of data collected through their use of the Wash’Em Rapid Assessment tools in a particular setting. The summary data takes the form of responses to multiple-choice questions. The datasets do not represent individual-level behaviour or opinions but rather common patterns of behaviour or opinion in each region. The owners of the datasets are identified by name, organisation and email address in the software and are typically staff of non-government organisations.

Eligibility and data validation

The owners of all datasets available in the Wash’Em Programme Designer software database were contacted and asked for informed consent to utilise the data they had submitted into the software for the purpose of this study. If the user had not responded after the third email their dataset was not included in the study. Datasets were otherwise eligible for inclusion if they were dated between March 2020 and June 2021, if all required multiple-choice questions were complete, and if the organisation described the health outcome of interest as being COVID-19. Datasets were excluded if they indicated they were clearly marked as test data. To confirm that all datasets reflected an actual use of the Wash'Em process and understand how the process was used during the pandemic, dataset owners were asked to complete an online survey. The survey was designed to understand the quality of the dataset and whether it was collected by following the intended Wash'Em process. The survey included questions about how staff were trained, who was involved in data collection and how long this took, the modality of data collection, and how recommendations were used. Follow up emails were sent to users to clarify responses to certain questions as necessary. Datasets were excluded if responses to the survey were not aligned with the intended Wash'Em process.

Data analysis

Data from the Wash’Em Programme Designer software and survey responses were exported to Microsoft Excel and cleaned. The data were checked to identify any missing values, and consistency checks were completed. Descriptive analysis was conducted in Stata 16 (StataCorp 2015, College Station, TX, USA). To explore the homogeneity of contextual factors, programming and the determinants of hand hygiene behaviour across countries and use cases, we developed a heat map to compare user responses to the multiple-choice questions in the software. The colours of the tiles within the heatmap were determined by the proportion of responses to each part within each question. Fleiss’s Kappa (32) was then used to assess the level of agreement in user responses within each of the sections of the software. The R statistical software was used (R Core Team 2018).

In total, 220 datasets were added to the Wash’Em software between March 2020 and June 2021. 62 of these datasets were discarded as they were marked as test data by the users. Owners of the remaining 158 datasets were contacted to seek consent and validation. In total, 48 datasets were verified, and owners provided informed consent for the data to be used for research purposes. However, only 38 of the datasets stated that COVID-19 was one of the health outcomes of interest. Table 1 summarises the characteristics of the contexts these 38 datasets came from.

Table 1

A summary of the contexts where Wash'Em was used as part of COVID-19 response
Contexts where Wash’Em was used as part of COVID-19 response	Number	Percentage
Number of humanitarian organisations using Wash’Em to inform their COVID-19 response during the study period.	38	100%
Number of countries represented by the data sets
Sub-Saharan Africa	18	47%
Latin America and the Caribbean	13	34%
East Asia and Pacific	4	11%
Other (Middle East, North Africa, South Asia and Europe)	3	8%
Disease outcome of interest identified in the datasets
COVID-19	38	100%
Diarrhoeal diseases or respiratory infections	30	79%
Other outbreak-related disease (e.g. Cholera or Ebola)	19	50%
Datasets indicating they were responding to multiple crises
COVID-19 and another disease outbreak	26	68%
COVID-19 and a disaster	11	29%
COVID-19 and armed conflict or political or social unrest	13	34%
Duration of the humanitarian crisis
More than 10 years	7	18%
5 to 10 years	1	3%
1 year to 5 years	9	24%
6 months to a year	5	16%
Within the last 6 months	15	39%
Within the last month	0	0%
Location of the target population
People residing in a formal camp setting	9	24%
People residing in an informal or unregulated camp settings	8	21%
Damaged buildings	2	5%
Their homes, in their place of origin	28	74%
Host communities in another community, not their place of origin	5	13%
People are on the move and have no regular place of residence	4	11%
Diversity of the target population
From a similar religious or cultural background	19	50%
Multiple religious or cultural groups in the area of operation	19	50%
Access to latrines
Most of the population have access to household latrines	12	32%
Most of the population have access to shared latrines	18	50%
Most of the population practice open defecation	7	18%
Responsibility for handwashing infrastructure, water and soap
Humanitarian organisations responsible	18	47%
Households responsible	20	53%

Contexts where Wash’Em was used

The main regions where COVID-19 response programs adopted Wash’Em were Sub-Saharan Africa and Latin America and the Caribbean. In many of these settings COVID-19 was not the only disease outcome targeted by the hygiene programme, with 79% of programmes targeting diarrhoeal diseases or respiratory infections more generally and 68% also targeting other outbreak-related diseases, such as Ebola and Cholera (Table 1). Similarly the majority of Wash’Em users were responding to ongoing protracted humanitarian crises in addition to COVID-19. For example, 29% were delivering programmes in the wake of a disaster, and 34% were working in settings which were experiencing armed conflict or political or social unrest. The majority of programmes (63%) included a focus on people who were displaced. Programmes targeted both displaced populations and host communities. Exposure to risk and loss was common, with two-thirds of Wash’Em users reporting that the targeted populations had lost either their house or belongings due to prior or ongoing humanitarian crises. This has left humanitarian crisis-affected populations little or no option but to either reside in formal or informal camp settings (17, 45%), with host communities (5, 13%), or to remain on the move (4, 11%). Whilst others live in their own homes in their place of origin (28, 78%).

Fifty percent of the included Wash’Em projects were delivered in regions where the majority of respondents had access to shared latrines, 7 (18%) of Wash’Em projects said that open defecation was most common in their area of operation, with the other projects reporting household level latrine ownership. 20 (53%) of the projects using Wash’Em indicated that households were responsible for the provision of handwashing infrastructure, soap and water in their settings while the remainder indicated that this responsibility for provision fell to humanitarian organisations or the local government.

Programme Constraints

Over half of the projects using Wash’Em as part of their COVID-19 response programmes indicated that their programme duration was six months or less (20, 53%), 21% indicated that their programme would cover a timeline of between six months to one year (8, 21%) and the remaining 26% indicated their programme would run for one to two years. The amount of funds available for hygiene programming (including human resources) varied across the projects which Wash’Em was part of, however 53% of projects were working with budgets of less than USD $50,000.

The correlation between the duration of the grant and the funding allocated for hygiene programming is presented in Table 2. This illustrates that the majority of COVID-19 programmes that used Wash’Em covered a short timeline and a relatively small injection of funds.

Table 2

Budget and timeframe available for COVID-19 focused hygiene programming during use of Wash’Em
Budget & Timeframe	Less than $10,000	USD $10,000 - $50,000	USD $50,000 - $100,000	USD $100 - $500,000	More than $500,000
6 months or less	11 (29%)	5 (13%)	3 (8%)	1 (3%)	0 (0%)
6 months to 1 year	1 (3%)	1 (3%)	2 (5%)	2 (5%)	1 (3%)
1 year to < 2 years	0 (0%)	2 (5%)	5 (13%)	4 (11%)	0 (0%)
More than 2 years	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)

Nearly half of the organisations using Wash’Em (18, 47%) worked in collaboration with other smaller local organisations or community volunteers to deliver their hand hygiene programmes. 26 (68%) of the organisations using Wash’Em anticipated that there would not be any barriers to effectively reaching populations during the pandemic. The remaining 32% indicated that programmatic activities were likely to be suspended due to safety and security concerns. In most projects, Wash’Em users reported that donors had not provided any specific direction on the delivery channels that they should use within their projects. Table 3 indicates the delivery channels that were recommended by donors during the pandemic, indicating that despite the health risks, a mix of in-person and remote delivery channels were still being encouraged.

Table 3

Delivery channels suggested by a donor for COVID-19 response
Delivery channels suggested by a donor for COVID-19 response	Number	Percentage
No channel suggested	15	39%
Radio	20	53%
Television	9	24%
House to house visits	18	47%
Mobile phones or social media	16	42%
Women’s groups, men’s groups or youth groups	18	47%

Patterns of Wash’Em Use

There were similarities in the ways organisations used Wash’Em during the pandemic. On average organisations trained 9.8 people (median of 3.5) on the Wash’Em process. Wash’Em provides a range of learning materials, including written guides, videos, in-person training, remote training, and role play guides for doing small-scale pilot data collection exercises. During the pandemic organisations used a mix of these training tools, as is recommended, however a relatively high proportion of users (18, 47%) opted to deliver Wash’Em trainings remotely.

Wash’Em training ranged from 0.5 to five days, with a median of two days. Thereafter, data collection using the Rapid Assessment Tools took on average two days to complete. In almost all cases organisations used all 5 Rapid Assessment Tools. One data set did not use the Touchpoint Tool, two did not use the Motives Tool, and six data sets did not use the Personal Histories Tool. However, the Wash’Em guidance does recommend omitting the Personal Histories tool in settings where supportive services (e.g. psychosocial support) are not present. The majority (36, 95%) of Wash’Em data collection was done fully face to face during the pandemic, despite recommendations to minimise face-to-face interactions. However, some users conducted remote interviews or FGDs through online platforms or phone calls.

At the point of being surveyed, 40% (15) Wash’Em users indicated that some or all of the Wash’Em programme recommendations had been implemented in their hygiene programmes. A further 37% (14) said they had been used but that the activities had to be adapted to suit their contexts better. One Wash’Em user said the recommendations had not been used while 5 others were intending to implement them soon. Follow up emails were sent to users who indicated that they had had to make adaptations to the programme recommendations, with the aim of understanding the kind of changes that occurred. Respondents indicated that most changes were to make the recommendations more feasible in their context. For example, one user explained that they combined two of the infrastructural activities (a competition to build or improve handwashing facilities and the distribution of mirrors to place over the handwashing facilities). Another indicated that they had adjusted the materials that were used in an activity due to the products that were available locally.

Handwashing determinants based on the Wash’Em Rapid Assessment Tools

Handwashing demonstrations

The Handwashing Demonstrations Tool is designed to understand how aspects of the behavioural setting [30, 31] enable or constrain the practice of handwashing. It involves asking people to demonstrate how they would normally wash their hands after using the toilet or before food preparation, videoing this sequence of action and then answering a set of questions about the availability, desirability and convenience of soap, water, and handwashing infrastructure. The tool also focuses on describing how the individual interacted with the setting to perform the behaviour. The Handwashing Demonstrations Tool is typically done with about 10 individuals, depending on the homogeneity of the setting and when a point of saturation is reached. It is recommended that participants are selected purposively to include a mix of ages, gender, abilities, socio-economic brackets, and variations within the local geography (e.g. access to water).

Among the included projects, only 4 (11%) reported that the majority of participant households had permanent dedicated handwashing facilities near the toilet or kitchen. 13 (34%) projects reported that the majority of households had no facilities at all. The remainder of the projects indicated that there was a place where hands were often washed but that this was done using mobile devices (e.g. use of a jug to pour water onto hands) or that people washed hands at multifunctional facilities (e.g. a shared tap stand). 10 (26%) projects reported that the handwashing facilities that did exist were convenient and easy to use, while the remainder indicated that the available facilities were often undesirable and unclean (16, 42%), were desirable and attractive (3, 8%), and clean and undesirable (8, 21%). Additional barriers to handwashing were identified through this tool including that handwashing facilities were often not at a convenient height (15, 40%), that the facilities allowed people to only wash one hand at a time (8, 21%), that the facilities were too far from the kitchen or toilet areas (13, 34%) and that handwashing infrastructure was fragile or easy to break (2, 5%).

Most projects (31, 82%) reported that households had soap available within the household. 16 (42%) projects had soap near the toilet, or in the kitchen, or at the handwashing facility. Meanwhile, 13 (34%) projects stored elsewhere in the house potentially making it potentially inconvenient to practice handwashing with soap and water at key times. Furthermore, 16 (42%) of the projects found that participants used products which were not primarily intended for handwashing (e.g. laundry soap, dishwashing liquid or ash) and 11 (29%) projects used bar soap designated for handwashing and bathing.

Like soap, water was found to be stored elsewhere in the house. 16 (42%) projects reported that the majority of Wash’Em research participants had to collect water from elsewhere in the compound and 4 (10%) reported water scarcity.

Disease Perception

The Disease Perception Tool helps Wash’Em users to understand local constructions of disease, health priorities, perceived vulnerability to the disease, the severity of health and non-health consequences of the disease, and action-efficacy related to disease prevention. The Tool is undertaken within focus group discussions (FGDs) typically involving 6–10 individuals. Wash’Em users are required to do a minimum of 2 FGDs, one with women and one with men but are also encouraged to do additional FGDs with other population sub-groups (e.g. older people, people with disabilities, young adults, etc.) to collect diverse opinions and ensure a degree of saturation is met. The Disease Perception Tool uses a colour coded Likert scale to encourage participants to debate how they feel about the disease-oriented questions. The tool can be adapted based on which disease outcome the users programme is trying to address (e.g. diarrhoeal diseases, respiratory infections, Ebola, Cholera, etc). However, among the included studies it was used to explore perceptions related to COVID-19.

30 (79%) of the included projects found that FGD participants listed COVID-19 among their five greatest health concerns at that point in time. Regarding perceived susceptibility, 15 (39%) of the projects reported that FGD participants thought they would definitely get COVID-19 in the next six months, whilst participants in 18 projects (47%) reported that they felt they might get infected during this time period. When asked who is more likely to get sick with COVID-19 between their own family and other families in the community, most projects (32, 84%) reported that participants felt they were all at equal risk of infection.

When asked about the perceived impacts associated with getting COVID-19. Wash’Em participants mentioned impacts on their physical and mental wellbeing (21, 58%). Economic impacts associated with either loss of income when sick (27, 75%), or costs associated with travelling to and accessing healthcare services were mentioned by 20 projects (56%). 16 projects (44%) found that participants were concerned about being less productive if they were to get COVID-19. Others mentioned social impacts that they associated with COVID-19 including with feeling isolated or stigmatised (17, 47%) or having to take on additional responsibilities because of others getting sick (11, 31%).

When asked about COVID-19 prevention, 24 projects (63%) reported that FGD participants felt that they were able to take actions to prevent the disease, however in 11 projects (29%) participants did not think that handwashing with soap was an effective mode of prevention. Despite this, in 16 projects (44%) participants reported that they thought handwashing behaviour had increased recently due to fear around COVID-19.

Motives

The Motives Tool explores motivations associated with handwashing behaviour, perceived identity, and aspirations. The Tool is also conducted within FGDs, with a similar sample process as for the Disease Perception Tool. When using the Motives Tool, facilitators introduce participants to a set of character cards. The character cards contain visuals and descriptions of a person with a particular characteristic. Each characteristic is linked to a core human motive as defined by Aunger and Curtis [32], with some adaptations made so that these were more relevant to the experiences of crisis or outbreak affected populations. For example, one character card depicts a person looking in the mirror who is described as a person who wants to look attractive. This character card is linked to the motive of attract. Another one of the cards shows someone socialising and they are described as a person who values having friends. This card is therefore linked to the motive of affiliation. In total there are 13-character cards. Once facilitators have introduced all the cards to participants, the participants are asked to rank the characters in order of who they think is most likely to always wash their hands with soap, down to who is least likely to do so. Participants are encouraged to debate and discuss the order of the cards. They are then asked to talk about which characters they currently feel like and which they aspire to be like.

The motives most commonly associated with handwashing across all projects were status and disgust. FGD participants across all projects identified themselves as hard-working, neat and orderly. In most projects, FGD participants said that they aspired to be respected because of their education or wisdom, because they were good parents. Others aspired to be able to be neater and wealthy. Figure 1 illustrates what currently people feel like and their aspirations.

Personal Histories

Unlike the Wash’Em Tools described above, the Personal Histories Tool is not focused on handwashing behaviour specifically, but rather is designed to explore the broader experiences of a crisis or outbreak on people’s lives. The tool is done through individual interviews and there are different worksheets that can be used to explore experiences of displacement and conflict, experiences of disasters, or experiences during an outbreak of disease, such as COVID-19. In the included studies the worksheet related to outbreaks was used. This requires Wash’Em users to identify individuals who have recent experience with the disease (e.g. have recently recovered from COVID-19 and are no longer infectious or who have had a family member who was ill with the disease). Wash’Em users are required to do a minimum of six Personal History interviews and are encouraged to do more until a point of saturation is met. As with the Handwashing Demonstrations Tool participants are sampled purposively to reflect the diversity of the region. Staff facilitating the interviews start by asking the participant to draw three pictures of themselves or their life at different time points: prior to the outbreak, during their illness, and while recovering. The drawing process is designed to help participants open up about their experiences. Subsequent questions are then asked about how different aspects of their lives changed at each of these time points, including questions related to the individual’s role and responsibilities, their social life, their hopes and goals, and their perceived sense of control over aspects of their day-to-day life.

During the pandemic, 34 (89%) of projects found that interview participants reported their role within their family or community had changed. For example, parents often felt less able to provide for their families or fulfil their normal day-to-day duties/roles, or their professional role. Others reported taking on a role that they would not normally do because they have been separated from their immediate family or have been put in a difficult situation. Interview participants in 15 projects (45%) reported that friends and family had avoided them because of stigma. In 16 projects (48%) the majority of participants reported choosing to be less sociable during the pandemic. However, in 7 of the projects (21%) the interview participants felt their existing social network was a source of great support during the pandemic. 35 projects (92%) reported that interview participants said their hopes and goals for the future had changed because of their experiences associated with COVID-19. People reported an increased fear about their future and that of their children, including concerns around mental and physical health. Many felt that the future was in God's hands and there was little they could do. 23 projects (70%) reported that the majority of interview participants felt their economic situation was not precarious and 19 projects (57%) found that most participants felt that they had lost agency during the pandemic and were now reliant on others for basic aspects of survival.

Touchpoints

The final Wash’Em Tool, Touchpoints, is designed to understand the multiple ways that organisations could reach and engage with populations when delivering programmes. The Touchpoints Tool is done within FGDs, with sampling being similar to the Disease Perception Tool and the Motives Tool. Facilitators using this tool work with FGD participants to learn about which delivery channels are available, describe potential reach and reflect on whether there are certain population sub-groups who might not be reached through specific channels (e.g. women, men, children, older people or people with disabilities). The Tool also asks participants about whose views or opinions they listen to and respect.

Among the included projects, the three most effective Touchpoints for reaching crisis-affected populations during the pandemic were television (prioritised in 26 projects, 68%), radio (prioritised in 22 projects, 58%), and mobile phones (prioritised in 20 projects, 53%). To a lesser extent, local information sharers (e.g. town criers), religious institutions and health workers were also highlighted as other important ways of engaging with communities. When FGD participants were asked about whose opinions they respected most, community leaders or elders and religious leaders were reported by the majority of FGD participants (87% and 84% of projects respectively).

Consistency in the determinants of hand hygiene behaviour across contexts

Figure 2 is a heatmap illustrating the level of consistency in user responses to the Wash’Em questions (all questions and response options are available in SM2) and is divided by each of the sections in the software. Bright yellow colours, which indicate a high proportion of sites selecting the same response, are not common. Responses tended to be varied for most questions. There was a low level of homogeneity across the 38 COVID-19 datasets in terms of both the contextual factors, programming constraints and determinants of handwashing behaviour during the pandemic. This is supported by the Fleiss’ Kappa results, which for all categories indicated poor agreement or slight agreement only (most were approximately 0.20 or lower) [33]. Higher levels of agreement across the datasets were seen within the responses to questions on programmatic context and constraints, motives and disease perception and delivery channels.

The coincidental launch of Wash’Em in March 2020, just as the COVID-19 pandemic was spreading around the world, provided a unique opportunity to learn about hygiene programme design and the determinants of handwashing behaviour across multiple fragile settings that were facing the same health threat. Our findings provide insights into the applied used of a novel process like Wash’Em for supporting humanitarian hygiene programming, while also generating more transferable learning about the determinants of behaviour during outbreaks and how these vary by context.

Learning about the Wash’Em process and its utility for informing outbreak responses

Our findings indicate that during the pandemic Wash’Em was used in a way that was consistent with the intended process. Specifically, it appeared to be an approach which could be feasibly implemented by a small team of humanitarian staff and typically conducted within a week. Despite an increasing amount of remote data collection taking place during the pandemic [34] this multi-country analysis indicated that the majority of users opted for in-person data collection using these tools. Our data also indicated that many users still felt the need to further contextualise and adapt the Wash’Em recommendations and this is something merits further exploration so that clearer guidance can be provided to users about implementation strategies. We found that Wash’Em was typically used within short-term COVID-19 response programmes where hygiene-related prevention activities comprised a relatively small percentage of the budget. This is consistent with broader evidence which indicates that hygiene promotion has historically been underfunded [35] and major gaps exist in terms of what it would take to effectively finance hygiene globally [36, 37]. However, it is surprising that this pattern of underfunding persisted during the pandemic, when increasing global attention was given to improving handwashing behaviour [7, 38].

During the COVID-19 pandemic, and indeed during prior outbreaks, the majority of research and programming disproportionally focused on assessing behavioural determinants such as knowledge, risk and fear [25, 39–43]. While Wash’Em does generate learning on these determinants it intentionally also assesses a more diverse set determinants including factors related to the physical and social environments. By taking this more holistic view Wash’Em users were able to build up a more nuanced understanding of the barriers and enablers of handwashing behaviour.

The determinants of handwashing behaviour during outbreaks

Our descriptive and statistical analysis of Wash’Em data from 38 project settings during the pandemic indicated that the determinants of handwashing behaviour during outbreaks are predominantly shaped by the context rather than the nature of the health threat. One explanation for this is that the COVID-19 pandemic did not bring about a substantial shift in the underlying circumstances that create disease vulnerability. For example, the presence of a conveniently located and desirable handwashing facility with soap and water available is recognised to be a critical enabler of regular handwashing practice [25]. However, consistent with global data on handwashing facility access [7, 44, 45] and water and soap availability [46–48], our findings from the Handwashing Demonstration Tool showed that in fragile contexts desirable handwashing infrastructure, as well as access to water and soap, were major barriers to behaviour during the pandemic. Similarly, findings from the Personal Histories Tool indicated the profound non-health impacts of the pandemic on people’s lives, particularly in settings where people were already dealing with co-existing outbreaks and crises. The majority of programmes identified major shifts in the way participants perceived their role in the family or community, their agency, and their economic fragility during the pandemic - findings which are consistent with broader research in LMIC settings [49–52] but which are rarely considered when designing hygiene prevention programmes [53]. Stigma and isolation were commonly reported among those directly affected by COVID-19. While this was raised as a concern during the pandemic [54, 55], research on this within LMICs is lacking and merits further investigation.

Perhaps unsurprisingly, there were slightly higher levels of homogeneity in terms of responses to the Disease Perception Tool. COVID-19 was seen as a major health concern by Wash’Em participants in most programmes and most people felt they were vulnerable to getting the disease. Within many of the Wash’Em use cases, participants doubted the efficacy of handwashing to interrupt COVID-19 transmission, yet still reported increases in community-level handwashing behaviour. This seemingly contradictory finding that outcome expectancy (e.g. the belief that handwashing is effective in preventing COVID-19) is not a particularly strong motivator of behaviour has also been identified in other studies during the pandemic [56]. Greater homogeneity in responses was also observed in relation to the Touchpoint Tool which identified mass and digital media as key modalities for reaching people remotely during the pandemic. Despite variations in access to mass and digital media within many LMIC settings [57] it would seem that these channels, as well as the engagement of community leaders, are promising avenues for the delivery of outbreak interventions.

Limitations

While the follow up survey with users was designed to help verify the data and ensure that it was collected in the way intended by the Wash’Em process, the survey still required users to self-report their experiences and this may have been affected by recall or social desirability bias. This, together with the brevity of the survey, means that we may not have identified key challenges related to data collection quality, which may have in turn affected the overall patterns observed. Some data collection errors are likely within this dataset, given that it was collected by 38 different teams of humanitarian staff.

Wash’Em intentionally collects data from a small number of people within the crisis or outbreak affected population. This is done with the aim of making the approach feasible for humanitarian actors needing to respond quickly in crises, and because the data is designed to inform programming only (rather than being seen as independently valid in-depth or representative research). Users are encouraged to continue with data collection until a point of saturation is reached for each Rapid Assessment Tool. However, from the summary data inputted into the software it is not possible to see how many individuals actually participated in each use case. Inferring common patterns across this data, as we have done in this manuscript, may therefore mean quite different things in each use case. For example, a common pattern that occurs across 3 FGDs may have occurred by chance and would be a less reliable finding than if this common pattern had emerged across a larger number of FGDs.

Historically, hygiene programmes that have been delivered during outbreaks have been criticised for ‘cutting and pasting’ programmatic interventions from one setting to another, with limited community engagement or contextualisation [58–60]. Our findings support the need for the assessment of behavioural determinants prior to intervention design so that programmatic activities can address pre-existing and emergent factors that influence behaviour and create disease vulnerabilities. Based on this multi-country analysis, Wash’Em appears to be one such example of a feasible approach for holistically understanding the determinants of handwashing behaviour in fragile and outbreak affected settings.

The findings also have broader implications for the way we think about hygiene programme design in humanitarian crises and outbreaks. Specifically, it is critical that such programmes go beyond just assessing cognitive determinants of behaviour (such as knowledge and risk perception), but also consider social and physical determinants which are likely to shape behaviour. Similarly, it is important that responses to any emerging health threat consider the secondary non-health impacts of outbreaks and the competing priorities of populations living in fragile LMICs. These broader, context-dependent factors appear to substantially influence disease vulnerability and behavioural responses.

Acknowledgements

We would like to thank the humanitarian organisations that utilised Wash’Em in the design of hand hygiene programmes during the COVID-19 pandemic and who were willing to share their datasets with us, for analysis as part of this research. We also extend gratitude to the humanitarian crises affected populations who were affected by COVID-19 and were part of the Wash’Em process. Special thanks go to Sian White and William Thorsen who played a critical role in the design of the rapid assessment tools and Wash’Em software. This research was undertaken as part of the Wash’Em project, which aims to improve handwashing promotion in humanitarian crises. The research was made possible by the generous support of the American people through the United States Agency for international development’s Bureau of Humanitarian Assistance. The contents are the responsibility of the authors of the paper and do not necessarily reflect the views of USAID or the United States Government.

Acknowledgements

SW and AHT conceptualised and designed the study. AHT conducted data collection, cleaning and analysis. JL also conducted data analysis and was responsible for writing the paper. AMD supported with data analysis by presenting the findings through heat maps. SW and WT reviewed and edited the manuscript. All authors read and approved the final manuscript.

Funding

This research was supported by the United States Agency for International Development’s Bureau of
Humanitarian Assistance (grant number: AID-ODA-G-16-00270). The funding body played no role in the design of the study, the collection, analysis, and interpretation of data or in writing the manuscript. The contents are the responsibility of the authors of the paper and do not
necessarily reflect the views of USAID or the United States Government.

Availability of data and materials

The datasets used and/or analysed during the study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Ethics approval for this secondary data analysis was provided by the ethics committee at the London School of Hygiene and Tropical Medicine (Approval ID: 25092). Humanitarian organisations sought informed verbal or written consent from individuals that they collected data from when using the Wash’Em Rapid Assessment Tools. A second level of written consent was sought from humanitarian organisations to include their anonymous summary data within this study.

Consent for publication

Wash’Em users provided written consent for the use of their datasets within this study and for the findings to be published.

Competing interests

WT and SW were involved in the design of the Rapid Assessment Tools and Wash’Em Software.

McCann G, Matenga C. COVID-19 and global inequality. COVID-19 in the Global South, 2020. 2683: p. 161.
Schellekens P, Sourrouille DM. COVID-19 mortality in rich and poor countries: a tale of two pandemics? World Bank Policy Research Working Paper, 2020(9260).
Alawa J, et al. Addressing COVID-19 in humanitarian settings: a call to action. Confl Health. 2020;14(1):64.
Dahab M, et al. COVID-19 control in low-income settings and displaced populations: what can realistically be done? Confl Health. 2020;14(1):54.
Hargreaves S, et al. Targeting COVID-19 interventions towards migrants in humanitarian settings. Lancet Infect Dis. 2020;20(6):645–6.
Raju E, Ayeb-Karlsson S. COVID-19: How do you self-isolate in a refugee camp? Int J Public Health. 2020;65(5):515–7.
Brauer M et al. Global Access to Handwashing: Implications for COVID-19 Control in Low-Income Countries. Environ Health Perspect. 128(5): p. 057005.
Jordan K, Lewis TP, Roberts B. Quality in crisis: a systematic review of the quality of health systems in humanitarian settings. Confl Health. 2021;15(1):7.
Grijalva-Eternod CS, et al. The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees. PLoS Med. 2012;9(10):e1001320.
Aebischer Perone S, et al. Non-communicable diseases in humanitarian settings: ten essential questions. Confl Health. 2017;11(1):17.
Hunt X, Banks LM. The Health of People with Disabilities in Humanitarian Settings During the Covid-19 Pandemic. IDS Bull, 2022. 53(2).
Charlson F, et al. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. The Lancet. 2019;394(10194):240–8.
Nachega JB, et al. Responding to the Challenge of the Dual COVID-19 and Ebola Epidemics in the Democratic Republic of Congo-Priorities for Achieving Control. Am J Trop Med Hyg. 2020;103(2):597–602.
Uwishema O, et al. Threats and outbreaks of cholera in Africa amidst COVID-19 pandemic: a double burden on Africa’s health systems. Trop Med Health. 2021;49(1):93.
Glassman A, Chalkidou K, Sullivan R. Does one size fit all? Realistic alternatives for COVID-19 response in low-income countries. Volume 2. Center for Global development; 2020.
Coetzee BJs, Kagee A. Structural barriers to adhering to health behaviours in the context of the COVID-19 crisis: Considerations for low- and middle-income countries. Glob Public Health. 2020;15(8):1093–102.
Singh NS, et al. COVID-19 in humanitarian settings: documenting and sharing context-specific programmatic experiences. Confl Health. 2020;14(1):79.
World Health Organization and United Nations Children's Fund. Water, sanitation, hygiene and waste management for COVID-19: technical brief, 03 March 2020. World Health Organization: Geneva; 2020.
Beale S, et al. Hand Hygiene Practices and the Risk of Human Coronavirus Infections in a UK Community Cohort. Wellcome Open Res. 2020;5:98.
Abdullahi L, et al. Community interventions in Low—And Middle-Income Countries to inform COVID-19 control implementation decisions in Kenya: A rapid systematic review. PLoS ONE. 2020;15(12):e0242403.
Talic S, et al. Effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality: systematic review and meta-analysis. BMJ. 2021;375:e068302.
Wolf J, et al. Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression. Trop Med Int Health. 2018;23(5):508–25.
Chirgwin H, et al. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. Campbell Syst Reviews. 2021;17(4):e1194.
Jefferson T et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane database of systematic reviews, 2020(11).
White S, et al. The determinants of handwashing behaviour in domestic settings: An integrative systematic review. Int J Hyg Environ Health. 2020;227:113512.
White S et al. How does hygiene behaviour change over the course of displacement? A qualitative case study in Iraq and Kurdistan. PloS One, In Press.
White S et al. How does handwashing behaviour change in response to a cholera outbreak? A qualitative case study in the Democratic Republic of the Congo. In Press.
Zangana A, et al. The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq. PLoS ONE. 2020;15(5):e0231694.
White S. Wash’Em and the COVID-19 response, in Wash'Em Guides. Wash'Em Website; 2020.
Curtis V, et al. Behaviour settings theory applied to domestic water use in Nigeria: A new conceptual tool for the study of routine behaviour. Volume 235. Social Science & Medicine; 2019. p. 112398.
Barker RG. Ecological Psychology: Concepts and methods for studying the environment of human behavior. Palo Alto, CA: Stanford University Press; 1968.
Aunger R, Curtis V. Behaviour Centred Design: Toward and applied science of behaviour change.. Health Psychol Rev, 2016.
Nichols TR, et al. Putting the Kappa Statistic to Use. Qual Assur J. 2010;13(3–4):57–61.
Hensen B, et al. Remote data collection for public health research in a COVID-19 era: ethical implications, challenges and opportunities. Health Policy Plann. 2021;36(3):360–8.
Organization WH. National systems to support drinking-water: sanitation and hygiene: global status report 2019: UN-Water global analysis and assessment of sanitation and drinking-water: GLAAS 2019 report. 2019.
Ross I et al. Costs of hand hygiene for all in household settings - estimating the price tag for the 46 least developed countries. medRxiv, 2021: p. 2021.08.16.21262011.
Hutton G, Varughese M. The costs of meeting the 2030 sustainable development goal targets on drinking water, sanitation, and hygiene. 2016.
Giné-Garriga R, et al. COVID-19 water, sanitation, and hygiene response: Review of measures and initiatives adopted by governments, regulators, utilities, and other stakeholders in 84 countries. Sci Total Environ. 2021;795:148789.
Olapeju B, et al. Trends in handwashing behaviours for COVID-19 prevention: Longitudinal evidence from online surveys in 10 sub-Saharan African countries. PLOS Global Public Health. 2021;1(11):e0000049.
Al-Wutayd O, et al. Handwashing knowledge, attitudes, and practices during the COVID-19 pandemic in Saudi Arabia: A non-representative cross-sectional study. Sci Rep. 2021;11(1):16769.
Xu H, et al. Relationship between COVID-19 infection and risk perception, knowledge, attitude, and four nonpharmaceutical interventions during the late period of the COVID-19 epidemic in China: online cross-sectional survey of 8158 adults. J Med Internet Res. 2020;22(11):e21372.
Yıldırım M, Geçer E, Akgül Ö. The impacts of vulnerability, perceived risk, and fear on preventive behaviours against COVID-19. Psychol Health Med. 2021;26(1):35–43.
Krägeloh CU, et al. Physical Distancing and Hand Washing During the COVID-19 Pandemic Among Saudi Adults: the Role of Fear, Perceived Seriousness, and Health Knowledge. International Journal of Mental Health and Addiction; 2021.
Wolf J, et al. Handwashing with soap after potential faecal contact: global, regional and country estimates. Int J Epidemiol. 2019;48(4):1204–18.
Moffa M, et al. Measuring household hygiene access and handwashing behaviors: Findings from 14 low- and middle-income countries. Int J Hyg Environ Health. 2021;237:113810.
Jiwani SS, Antiporta DA. Inequalities in access to water and soap matter for the COVID-19 response in sub-Saharan Africa. Int J Equity Health. 2020;19(1):82.
Stoler J, et al. Household water insecurity will complicate the ongoing COVID-19 response: Evidence from 29 sites in 23 low- and middle-income countries. Int J Hyg Environ Health. 2021;234:113715.
Ekumah B, et al. Disparate on-site access to water, sanitation, and food storage heighten the risk of COVID-19 spread in Sub-Saharan Africa. Environ Res. 2020;189:109936.
Banati P, Jones N, Youssef S. Intersecting Vulnerabilities: The Impacts of COVID-19 on the Psycho-emotional Lives of Young People in Low- and Middle-Income Countries. Eur J Dev Res. 2020;32(5):1613–38.
Sumner A, Ortiz-Juarez E, Hoy C. Precarity and the pandemic: COVID-19 and poverty incidence, intensity, and severity in developing countries. 2020: WIDER working paper.
Govender K, et al. Beyond the disease: Contextualized implications of the COVID-19 pandemic for children and young people living in Eastern and Southern Africa. Front Public Health. 2020;8:504.
Buheji M, et al. The extent of covid-19 pandemic socio-economic impact on global poverty. a global integrative multidisciplinary review. Am J Econ. 2020;10(4):213–24.
White S, et al. How does handwashing behaviour change in response to a cholera outbreak? A qualitative case study in the Democratic Republic of the Congo. PLoS ONE. 2022;17(4):e0266849.
Roelen K, et al. COVID-19 in LMICs: The Need to Place Stigma Front and Centre to Its Response. Eur J Dev Res. 2020;32(5):1592–612.
Peprah P, Gyasi RM. Stigma and COVID-19 crisis: A wake-up call. Int J Health Plann Manage. 2021;36(1):215–8.
Lao CK, et al. Using the health action process approach to predict facemask use and hand washing in the early stages of the COVID-19 pandemic in China. Current Psychology; 2021.
Hernandez K, Roberts T. Leaving no one behind in a digital world. 2018.
Czerniewska A, White S. Hygiene programming during outbreaks: a qualitative case study of the humanitarian response during the Ebola outbreak in Liberia. BMC Public Health. 2020;20(1):154.
Vujcic J, Ram PK, Blum LS. Handwashing promotion in humanitarian emergencies: strategies and challenges according to experts. J Water Sanitation Hygiene Dev. 2015;5(4):574–85.
White S et al. How are hygiene programmes designed in crises? A qualitative study of the perspectives of humanitarians in the Democratic Republic of the Congo and Iraq. 2022.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

The determinants of handwashing during the COVID-19 pandemic: A multi-country analysis of data from the Wash’Em process for hygiene programme design

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Data analysis

Results

Handwashing demonstrations

Disease Perception

Motives

Personal Histories

Touchpoints

Discussion

Conclusion

Declarations

Acknowledgements

Acknowledgements

Funding

Availability of data and materials

Ethics approval and consent to participate

Consent for publication

Competing interests

References

Additional Declarations

Supplementary Files

Status:

Version 1