Child handwashing in an internally displaced persons camp in Northern Iraq: A qualitative multi-method exploration of motivational drivers and other handwashing determinants

Abstract

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.

Embracing challenging complexity: exploring handwashing behavior from a combined socioecological and intersectional perspective in Sierra Leone

“…Moreover, handwashing frameworks have been criticized for their bias towards certain sets of determinants (e.g., individual-level or structural determinants) because they risk missing its complexity [ 17 ]. In contrast, socioecological frameworks allow for the conceptualization of multi-level determinants of handwashing and have shown the high relevance of social- and structural-level factors in addition to individual factors [ 58 , 59 ]. However, they do not explicitly take into account power gradients and differing degrees of vulnerability between groups in a shared social setting.…”

How is hygiene behaviour affected by conflict and displacement? A qualitative case study in Northern Iraq

“…Actual or perceived scarcities of water and soap and the de-prioritisation of these items for handwashing (as opposed to other household tasks) have been identified as common challenges in the wake of humanitarian crises [ 49 – 52 ]. The availability of desirable and conveniently located handwashing facilities is thought to be one of the most influential determinants of hygiene behaviour in stable settings [ 7 , 12 , 53 ] and improving handwashing infrastructure may have an even greater influence among displaced populations [ 51 , 54 , 55 ].…”

“…Our study found handwashing was most strongly influenced by motives of disgust, status and comfort. Other studies among displaced populations have suggested motives of nurture and affiliation should be utilised by hygiene programmes in humanitarian settings [ 51 , 56 , 57 ]. The use of emotional drivers in hygiene programming remains contentious.…”

Kukaa Salama (Staying Safe): study protocol for a pre/post-trial of an interactive mHealth intervention for increasing COVID-19 prevention practices with urban refugee youth in Kampala, Uganda

“…For instance, we identified no respiratory hygiene intervention studies in humanitarian contexts. [14][15][16] Humanitarian context hand hygiene studies report that information is necessary-but not sufficient-to motivate hand hygiene [17][18][19] and call for behaviour change strategies. 18 No adolescent/youth hand hygiene studies were located in humanitarian contexts.…”

“…A study with internally displaced children in Iraq identified hand hygiene determinants included hygiene promotion, social norms and motivational drivers. 19 A hand hygiene study with displaced adults in the Democratic Republic of Congo highlighted the role of emotional and social motivators and a need for innovation. 20 Physical distancing is not feasible in crowded settlements, 21 yet limited research has assessed strategies to promote alternatives such as household or community shielding.…”