In humanitarian emergency settings there is need for low cost and rapidly deployable interventions to protect vulnerable children, in- and out-of-school, from diarrhoeal diseases. Handwashing with soap can greatly reduce diarrhoea but interventions specifically targeting children's handwashing behaviour in humanitarian settings have not been tested. Traditional children's handwashing promotion interventions have been school-focused, resource-intensive and reliant on health-based messaging. However, recent research from non-humanitarian settings and targeting adults suggests that theory-based behaviour change interventions targeting specific motives may be more effective than traditional handwashing interventions. In this proof-of-concept study we test, for the first time, the distribution of a modified soap bar, designed to appeal to the motives of play and curiosity, in a household-level, rapidly deployable, handwashing promotion intervention for older children in a humanitarian setting - an internally displaced persons camp in Iraqi Kurdistan. Out of five total blocks within the camp, one was assigned to intervention and one to control. 40 households from each assigned block were then randomly chosen for inclusion in the study and the practice of handwashing with soap at key times was measured at baseline and four weeks after intervention delivery. Children in intervention households received transparent soaps with embedded toys, delivered within a short, fun, and interactive household session with minimal, non-health-based, messaging. The control group received plain soap delivered in a short standard, health-based, hygiene promotion session. At the 4-week follow-up, children in the intervention group were 4 times more likely to wash their hands with soap after key handwashing occasions than expected in the counterfactual (if there had been no intervention) based on the comparison to children in the control group (adjusted RR = 3.94, 95% CI 1.59-9.79). We show that distributing soaps with toys embedded inside, in a rapidly deployable intervention, can improve child handwashing behaviour in a humanitarian emergency context. Further studies are needed to determine the longer-term behavioural and health impact of such an intervention when delivered at a greater scale in a humanitarian context.

Background: Despite the widespread reliance on mobile clinics for delivering health services in humanitarian emergencies there is little empirical evidence to support their use. We report a narrative systematic review of the empirical evidence evaluating the use of mobile clinics in humanitarian settings. Methods: We searched MEDLINE, EMBASE, Global Health, Health Management Information Consortium, and The Cochrane Library for manuscripts published between 2000 and 2019. We also conducted a grey literature search via Global Health, Open Grey, and the WHO publication database. Empirical studies were included if they reported on at least one of the following evaluation criteria: relevance/appropriateness, connectedness, coherence, coverage, efficiency, effectiveness, and impact.Findings: Five studies met the inclusion criteria: all supported the use of mobile clinics in the particular setting under study. Three studies included controls. Two studies were assessed as good quality. The studies reported on mobile clinics providing non-communicable disease interventions, mental health services, sexual and reproductive health services, and multiple primary health care services in Afghanistan, the Democratic Republic of the Congo , Haiti, and the Occupied Palestinian Territories. Studies assessed one or more of the following evaluation domains: relevance/appropriateness, coverage, efficiency, and effectiveness. Four studies made recommendations including: i) ensure that mobile clinics are designed to complement clinic-based services; ii) improve technological tools to support patient follow-up, improve record-keeping, communication, and coordination; iii) avoid labelling services in a way that might stigmatise attendees; iv) strengthen referral to psychosocial and mental health services; v) partner with local providers to leverage resources; and vi) ensure strong coordination to optimise the continuum of care. Recommendations regarding the evaluation of mobile clinics include carrying out comparative studies of various modalities (including fixed facilities and community health workers) in order to isolate the effects of the mobile clinics. In the absence of a sound evidence base informing the use of mobile clinics in humanitarian crises, we encourage the integration of: i) WASH services, ii) nutrition services, iii) epidemic surveillance, and iv) systems to ensure the quality and safety of patient care. We recommend that future evaluations report against an established evaluation framework. Conclusion: Evidence supporting the use of mobile clinics in humanitarian emergencies is limited. We encourage more studies of the use of mobile clinics in emergency settings.

Recent systematic reviews have highlighted a paucity of rigorous evidence to guide water, sanitation and hygiene (WASH) interventions in humanitarian crises. In June 2017, the Research for Health in Humanitarian Crises (R2HC) programme of Elrha, convened a meeting of representatives from international response agencies, research institutions and donor organisations active in the field of humanitarian WASH to identify research priorities, discuss challenges conducting research and to establish next steps. Topics including cholera transmission, menstrual hygiene management, and acute undernutrition were identified as research priorities. Several international response agencies have existing research programmes; however, a more cohesive and coordinated effort in the WASH sector would likely advance this field of research. This report shares the conclusions of that meeting and proposes a research agenda with the aim of strengthening humanitarian WASH policy and practice.

Background Children in humanitarian situations are particularly vulnerable to diseases such as diarrhoea. Handwashing with soap can greatly reduce transmission but handwashing rates are often low and traditional interventions ineffective. To aid future intervention design, this study aims to understand the determinants of child handwashing and the key motivational drivers of children's behaviour within a specific humanitarian setting. Methods In an internally displaced persons camp in Northern Iraq we conducted a series of 36 friendship-paired interviews with children aged 7-12 years, six semi-structured caregiver interviews, and three semi-structured hygiene promoter interviews. Perceived determinants of child handwashing were explored qualitatively, and motivational drivers were explored quantitatively with children in a rating exercise. Qualitative data were analysed thematically, using an inductive approach, and logistic regression analyses of motive rating data were performed to determine the predicted probabilities of motives being rated as important. Results Access to soap and water was perceived to be high across all participant groups. Children, caregivers and hygiene promoters all perceive the determinants of child handwashing to be associated with familial role, environmental factors pertaining to location and quality of handwashing materials and facilities, and level of exposure to hygiene promotion, and children also attribute their handwashing to social norms. We find that children in this context are motived most by play and nurture.

Cholera remains a major public health problem in many countries. Poor sanitation and inappropriate clean water supply, insufficient health literacy and community mobilization, absence of national plans and cross-border collaborations are major factors impeding optimal control of cholera in endemic countries.In March 2017, a group of experts from 10 Asian cholera-prone countries that belong to the Initiative against Diarrheal and Enteric Diseases in Africa and Asia (IDEA), together with representatives from the World Health Organization, the US National Institutes of Health, International Vaccine Institute, Agence de médecine préventive, NGOs (Save the Children) and UNICEF, met in Hanoi (Vietnam) to share progress in terms of prevention and control interventions on water, sanitation and hygiene (WASH), surveillance and oral cholera vaccine use.This paper reports on the country situation, gaps identified in terms of cholera prevention and control and strategic interventions to bridge these gaps.