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

Abstract

Background Handwashing with soap is a cost-effective, efficient health behavior to prevent various diseases. Despite its immense health benefits, the lowest prevalence of handwashing is found in low-income countries. Here, its practice is not only determined by individual behavior, but also heavily shaped by deprivations in the social and structural ecology. Moreover, handwashing barriers are not equally experienced as overlapping social identities (e.g., age and gender) intersect and create inequities between members of different social groups. To embrace the complexities of handwashing beyond individual-level behavior and singular social identities, a combined socioecological and intersectional perspective is employed. This multi-level approach with regards to intersecting privileges and disadvantages serves as a basis to promote this highly important health behavior. Methods This study used a qualitative, theory-based approach and combined data from two samples: experts in health promotion (n = 22) and local citizens stratified by gender and rural/urban location (n = 56). Data was collected in face-to-face interviews in Sierra Leone between November 2018 and January 2019 and analyzed using thematic analysis and typology of the qualitative data. Results The conceptualization of multi-level determinants of handwashing within a socioecological model showed the high relevance of inhibiting social and structural factors for handwashing practice. By establishing seven distinguishing social identity dimensions, data demonstrates that individuals within the same social setting yet with distinct social identities experience strikingly differing degrees of power and privileges to enact handwashing. While a local leader is influential and may also change structural-level determinants, a young, rural wife experiences multiple social and structural constraints to perform handwashing with soap, even if she has high handwashing intentions. Conclusion This study provides a holistic analytical framework for the identification of determinants on multiple levels and accumulating intersections of socially produced inequalities for handwashing and is applicable to other health topics. As the exploration of handwashing was approached from a solution-focused instead of a problem-focused perspective, the analysis can guide multi-level intervention approaches (e.g., using low-cost, participatory activities at the community level to make use of the available social capital).

Who Has Access to Livestock Vaccines? Using the Social-Ecological Model and Intersectionality Frameworks to Identify the Social Barriers to Peste des Petits Ruminants Vaccines in Karamoja, Uganda

“…Figure 2 illustrates the factors livestock keepers interact with when it comes to accessing PPR vaccines at each socio-ecological level and the intersections across each [the framework was adapted from ( 50 )]. The intersectional lens illustrates how, even though some barriers are ubiquitous among livestock keepers (e.g., those at the Policy Level), the intersection of different social markers influences how these barriers are experienced.…”

“… SEM and Intersectionality frameworks for PPR vaccinations in Karamoja. The SEM was adapted from ( 37 ), and the combination of the SEM with the intersectional framework was adapted from ( 50 ). …”

“…In later iterations of analysis, these themes were corroborated, expanded upon, or refined, as certain themes across gender and different ethnic groups started to become recurrent. A modified version of the SEM ( 37 , 38 ), which incorporated an intersectional approach to explore the intersecting dimensions ( 50 ), was used to illustrate the factors that could be barriers to PPR vaccination practices in Karamoja. This version of the SEM has four levels: Individual, Social Environment, Physical Environment, and Policy Levels.…”

“…There is a growing body of literature that calls for the adaptation of social-ecological systems and models toward a One Health approach, inclusive of veterinary medicine ( 46 , 47 ). A few studies have used both SEM and intersectionality to understand socially complex situations ( 48 – 50 ). The use of both approaches allows stakeholders to understand how the intersection of different social markers could exacerbate or alleviate barriers at different levels in complex systems, but the integrated use of these approaches remains low and is, to our knowledge, inexistent in understanding livestock vaccines.…”

Collecting quantitative experimental data from a non-WEIRD population: challenges and practical recommendations from a field experiment in rural Sierra Leone

“…The present study describes challenges encountered during a mixed-methods field experiment aiming to increase domestic handwashing, which was carried out by researchers originating from a WEIRD (Germany) and non-WEIRD society (Sierra Leone) and implemented in a non-WEIRD country (Sierra Leone). Further details about the study design can be found in [ 7 , 8 ]. This study was planned and implemented under the lead of the first author in collaboration with a local investigator, the third author.…”