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PLOS ONE logoLink to PLOS ONE
. 2020 May 8;15(5):e0231694. doi: 10.1371/journal.pone.0231694

The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq

Aso Zangana 1, Nazar Shabila 2, Tom Heath 3, Sian White 4,*
Editor: Ginny Moore5
PMCID: PMC7209201  PMID: 32384095

Abstract

Background

Diarrhoea is one of the most common causes of mortality and morbidity among populations displaced due to conflict. Handwashing with soap has the potential to halve the burden of diarrhoeal diseases in crisis contexts. This study aimed to identify which determinants drive handwashing behaviour in post-conflict, displacement camps.

Methods

This study was conducted in two camps for internally displaced people in the Kurdistan Region of Iraq. A Barrier Analysis questionnaire was used for assessing the determinants of hand washing behaviour. Participants were screened and classified as either ‘doers’ (those who wash their hands with soap at critical times) or ‘non-doers’ (those who do not wash their hands with soap at critical times). Forty-five doers and non-doers were randomly selected from each camp and asked about behavioural determinants. The Barrier Analysis standard tabulation sheet was used for the analysis.

Results

No differences were observed between doers and non-doers in relation to self-efficacy, action efficacy, the difficulties and benefits of handwashing, and levels of access to soap and water. In the first of the two camps, non-doers found it harder to remember to wash their hands (P = 0.045), had lower perceived vulnerability to diarrhoea (P = 0.037), lower perceived severity of diarrhoea (P = 0.020) and were aware of ‘policies’ which supported handwashing with soap (P = 0.037). In the second camp non-doers had lower perceived vulnerability to diarrhoea (P = 0.017).

Conclusions

In these camp settings handwashing behaviour, and the factors that determine it, was relatively homogenous because of the homogeneity of the settings and the socio-demographics of population. Handwashing programmes should seek to improve the convenience and quality of handwashing facilities, create cues to trigger handwashing behaviour and increase perceived risk. We identify several ways to improve the validity of the Barrier Analysis method such as using it in combination with other more holistic qualitative tools and revising the statistical analysis.

Background

During conflicts, children under the age of five are twenty times more likely to die from diarrhoeal diseases rather than as a direct consequence of violence [1]. Handwashing with soap is considered to be one of the most cost-effective public health interventions [2] and has the potential to reduce diarrhoea by 23% to 48% [37]. However, the prevalence of handwashing with soap after contact with excreta is estimated to be 19% globally, and prevalence is even lower at other critical times (e.g. before food preparation, before eating, before feeding a child or after cleaning a child’s bottom) [8]. Despite the increased risk of diarrheal disease morbidity and mortality among displaced populations [9], handwashing rates remain sub-optimal in the aftermath of crises [10,11].

These low prevalence rates are unlikely to just be due to a lack of knowledge about the health benefits of handwashing. Studies have shown that even in areas of low literacy, populations are well able to explain the link between handwashing and disease avoidance [10,12]. Researchers working in non-emergency settings have identified a range of behavioural determinants likely to affect handwashing with soap. These determinants include the availability of handwashing facilities, soap and water; social norms and support mechanisms; motivations like disgust, nurture (the desire to do what is best for your child) and affiliation (the desire to fit in with a social group); risk perception; self-efficacy; and broader contextual factors [1317]. In the wake of a humanitarian crisis substantial programmatic attention is given to the promotion of handwashing with soap but often such programmes have been unable to achieve substantial behaviour change [11]. One reason for this may be that there is limited evidence about whether the determinants identified in stable settings are likely to be the same in crises situations.

In stable settings, we are increasingly seeing that hygiene programme designers incorporate a learning phase prior to programme design (often described as ‘formative research’) [8,12,1821]. This normally involves programme staff trying to understand the barriers and enablers of behaviour within a specific context. A mix of qualitative and quantitative methods are normally employed. Formative research can span from several weeks to many months and is a relatively resource heavy and high-capacity task. These time and resource demands mean that formative research is often compromised or omitted in humanitarian crises [22,23].

This study aims to contribute to improving our understanding of the determinants of behaviour in humanitarian crises. It does so by exploring barriers to handwashing with soap among women living in two displacement camps in the Kurdistan Region of Iraq (KRI). Through this research we also aim to determine whether existing, rapid methods assessing behavioural determinants are feasible to conduct in crisis settings. As such we have employed the Barrier Analysis approach in this study setting and seek to appraise the strengths and limitations of this tool.

Methods

Study site

This study was conducted in Duhok Province during June and July 2017. At this time 3.3 million Iraqis were displaced due to conflict [24]. Two camps for internally displaced persons (IDPs) were purposively selected to reflect different cultures, living conditions, durations of displacement, and different modalities of accessing hygiene infrastructure and products. The first, Nargazliya Camp (henceforth referred to as C1) housed 9,905 people at the time of this research. The population was predominantly Arab from the city of Mosul and its surrounding villages. C1 had been open for about six months at the time of this research and displaced people were still arriving on a daily basis, while others were beginning to return home to their villages. Sheikhan Camp (henceforth referred to as C2) was the other site selected for this research. Its population was more constant. At the time of this research C2 housed 5,371 Yazidi (Êzidî) people who had fled from the town of Sinjar and its surrounding villages in the summer of 2014.

Residents of both camps fled from areas which had been taken over by the Islamic State of Iraq and the Levant (ISIS). The nature of this crisis meant that all our research participants had been exposed to extreme violence in the past three years. Through consultations with camp residents and staff we learned that many people within the camps were still experiencing trauma at the time the research was conducted. Camp conditions generally met the SPHERE standards [25] but remained sub-optimal in many other ways. For example, at the time of this research the average temperature in these camps ranged between 45–50°C. Plastic tents and infrequent access to electricity meant that for most of the day there was no means of keeping cool. C1 was a ‘closed camp’ meaning that at the time of the research the population were unable to leave without formal permission. All communication equipment (e.g. phones or computers) was taken from C1 residents upon entry to the camp—a measure reportedly taken because of ‘security concerns’. Many of the residents had come from urban or peri-urban areas and were used to a relatively high standard of living prior to the conflict. For example, the displaced population would have previously been accustomed to pour-flush toilets and piped water.

In both camps water, sanitation and hygiene (WASH) infrastructure were provided to residents by non-government organisations (NGOs). In C1 WASH facilities were shared between six shelters (about 30 people), while in C2 each family had its own shower, toilet and kitchen. In both camps, water was stored in large tanks and accessible through taps inside the WASH facilities. There were no limitations on the amount of water the IDPs could consume in either camp. At the time of this research hygiene kit distribution (including soap) and hygiene promotion was ongoing in C1. Hygiene promotion was ongoing in C2, however, hygiene kit distribution had ceased and camp residents were responsible for buying their own soap. In both camps hygiene promotion was done by international and local NGOs in conjunction with hygiene promoters from the camp population. In both settings hygiene promotion was done through house-to-house visits. Hygiene promoters taught people a step-by-step process for how hands should be washed and used an image of the F-Diagram to explain faecal-oral disease transmission.

The barrier analysis method

Barrier Analysis is a standardised rapid assessment tool which is part of the Designing for Behaviour Change Framework [26]. The Barrier Analysis approach is intended to be used in advance of designing a behaviour change programme. It allows programme designers to identify key barriers and motivators of desirable behaviours (such as handwashing with soap) which can then be used to develop strategies for behaviour change. The Barrier Analysis approach can be considered to be part of a family of approaches which compare the perspectives of people who practice a behaviour (‘doers’) with those who do not practice the same behaviour (‘non-doers’). The RANAS framework, which is widely used in the WASH sector, also uses a doer/non-doer method for understanding behaviour [27]. These approaches are typically grounded in cognitive psychology and are designed with programme implementers in mind. The analysis process resembles that of a case-control study, allowing users to clearly pinpoint the factors that are most likely to enable or inhibit behaviour.

This study used the standardized Barrier Analysis questionnaire [28] for assessing the determinants of handwashing behaviour (S1 File). The Barrier Analysis approach was chosen for this research as it is widely used by the development and humanitarian sectors to inform behaviour change strategy. To date it has reportedly been used by more than 20 NGOs in 50 countries [29]. Despite the common usage of the Barrier Analysis approach, results and reflections on this method are rarely published in peer reviewed journals. Our research team was interested in identifying the strengths and limitations of the Barrier Analysis method and comparing findings with other observational and ethnographical data collection tools (these were implemented subsequently and will be reported elsewhere).

We started by defining the behaviour, the details of when and how this behaviour was to be practiced and priority groups whose behaviour we were interested in (see Table 1). This helped to inform our sampling and survey process. The Barrier Analysis questionnaire consists of two main parts. The first part is designed to classify the participant as either a ‘doer’ (a person who practices handwashing with soap) or a ‘non-doer’ (a person who does not practice handwashing with soap). The screening process used a combination of self-reported handwashing behaviour and proxy measures of handwashing behaviour (such as the observed presence of used soap at the handwashing facility). The second part of the questionnaire consisted of closed and open-ended questions exploring the 12 determinants of behaviour change. Specifically, the Barrier Analysis approach explores the following determinants: perceived self-efficacy, perceived social norms, perceived positive consequences, perceived negative consequences, access to products and services, cues to action, perceived susceptibility, and perceived vulnerability, perceived action efficacy, divine will, policy and culture. Table 1 provides a definition of each of these determinants drawn from the Barrier Analysis guidelines [28].

Table 1. Table of definitions based on the barrier analysis approach and adapted for this study.

Key term Definition
Target Behaviour Handwashing with soap
Priority groups Mothers of children under the age of five
Details of behaviour Handwashing with water and soap at critical times.
Critical times defined as 1) before preparing food, 2) before eating, 3) before feeding a child, 4) after using the toilet and 5) after cleaning a child’s bottom.
Perceived self-efficacy An individual's belief that he/she can wash their hands with soap given his/her current knowledge and skills.
Perceived social norms The perception that people important to an individual think that he/she should wash their hands with soap.
Perceived positive consequences The positive things a person thinks will happen as a result of handwashing with soap.
Perceived negative consequences The negative things a person thinks will happen as a result of handwashing with soap.
Access The availability of the needed products or services (e.g. soap, water, handwashing facilities) required for handwashing with soap. This includes barriers related to the cost, distance, and cultural acceptability of these products and services.
Cues to action / reminders The presence of reminders that help a person remember to wash their hands with soap.
Perceived susceptibility A person's perception of how vulnerable or at risk they are to getting diarrhoea.
Perceived vulnerability The extent to which a person believes that the diarrhoea is a serious illness.
Perceived action efficacy The extent to which a person believes that by practicing handwashing with soap they will be able to avoid getting diarrhoea.
Perceived divine will The extent to which a person believes that it is God’s will (or the gods’ wills) for him/her to get diarrhoea and/or to overcome it.
Policy The presence of laws and regulations that may affect whether people wash their hands with soap or which affect their access to relevant products and services.
Culture The extent to which local history, customs, lifestyles, values, and practices may affect whether people wash their hands with soap.

Enumerator training and questionnaire adaption

The data collection team underwent a three-day training conducted by the last author (SW). This included an overview of behaviour change and the Barrier Analysis questionnaire. The training involved opportunities to role-play using the BA questionnaire in the classroom, prior to piloting in the field sites. The data collection team translated the Barrier Analysis questionnaire into Arabic and Kurdish (Kurmanji). In order to arrive at the most accurate translated terms we used a process of brainstorming synonyms, back-translation and consultations with members of the local population through a focus-group discussion. Prior to the survey we pilot-tested the translated tool with a small number of households in the camps and made some small adjustments to enhance clarity.

Sampling

The study team administered the questionnaires to women who had a child under the age of five. These women were chosen as the target population because in this region they are the primary caregivers of children and responsible for most household tasks. Participants were selected through random sampling. Maps of both camps were obtained and each block was numbered. Blocks were selected using a random number generator on an Android device. A second random number was generated to select the shelter within the block. When we found a shelter that did not fulfil the criteria, or did not consent to participate, it was excluded, and we selected a neighbouring household by moving in a clockwise direction.

We aimed to select an equal number of doers and non-doers in each camp. The Barrier Analysis approach recommends a sample size of 45 doers and 45 non-doers. This relatively small sample size is argued to be sufficient because the Barrier Analysis method is designed to identify significant differences in behavioural determinants (defined as results with statistical significance of P<0.05) [30]. For this study, 45 doers and 45 non-doers were selected from each camp resulting in a total sample of 180 people. Participants continued to be screened and sampled until these figures were met.

Data collection and management

Data was collected by a team consisting of two persons, the lead author (AK—male) and a research assistant (female). Both individuals were present in all households to increase the acceptability of the questionnaire process. One person asked the questions while the other acted as a scribe, documenting by hand the key elements of the participant’s answer. Both team members spoke Arabic and Kurdish, with the questionnaire being administered in whichever language the participants felt most comfortable in. All responses were entered into an excel spreadsheet on the same day as it was collected to maintain quality and identify any missing data. If missing data was identified or responses were unclear, this process allowed us to return to the household the next day for clarification.

Data analysis

The data collection team and the last author classified the qualitative responses thematically, through a collective discussion. At the end of this process we tallied the number of responses in each category, and by their doer or non-doer classifications. These figures where then entered into the standardised Barrier Analysis tabulation sheet to draw conclusions from the data. This allows for closed-answer, quantitative data to be easily summarized and compared using the standard Barrier Analysis approach involving Chi-square tests and the generation of an odds ratio. The Barrier Analysis tabulation sheet highlights differences between doers and non-doers based on P values of ≤0.05.

Ethics

Informed written consent was obtained from each participant. The research was approved by the Ethics committees at the London School of Hygiene and Tropical Medicine and Hawler Medical University. Permission to work in both camps was provided by the Board of Relief and Humanitarian Affairs in Kurdistan and all non-government organisations in the camp were informed of our work.

Results

Classification of doers and non-doers

To be classified as a doer, participants had to mention at least three of the five critical handwashing times when asked ‘yesterday, what were all the moments that you washed your hands?’. They also had to report that they used soap when handwashing and had to have a used bar of soap present at the handwashing facility (based on a spot-check by the data collection team).

The most commonly reported ‘moment’ for handwashing with soap was before preparing food (number reporting this = 154/180). Doers in both camps were observed to have a used bar of soap near WASH facilities (in the kitchen or near the latrine). Only six non-doer households were found to not have soap. The majority of non-doers were found to keep their soap elsewhere in the house.

Perceived self-efficacy

Across both camps, all the doers felt that they were able to wash their hands with soap at the five critical times given their current knowledge, skills and their available resources. Most non-doers also reported feeling able to wash their hands at critical times (C1 = 96%, C2 = 98%).

When asked about factors that made handwashing easier, there was a high level of consistency between doers and non-doers and across the two camps. All the factors mentioned by participants were related to the availability and close proximity of resources such as piped water, soap and handwashing facilities (see Table 2). Participants in C2 were less likely than participants in C1 to mention that handwashing stations and soap increased their ease of handwashing (p = 0.002).

Table 2. Comparison of the doers and non-doers in the two camps regarding factors that make it easier to wash hands with soap.

Camp 1 Camp 2
Participant Responses Doers Non-Doers Difference Odds ratio P value Doers Non-Doers Difference Odds ratio P value
What makes it easier for you to wash your hands with soap at the five critical times each day?
Availability of piped water 44 (98%) 43 (96%) 2% 2.05 0.500 45 (100%) 43 (96%) 4%   0.247
Handwashing facilities are available 20 (44%) 18 (40%) 4% 1.20 0.416 10 (22%) 9 (20%) 2% 1.14 0.500
Close proximity of handwashing facilities 6 (13%) 3 (7%) 7% 2.15 0.242 3 (7%) 3 (7%) 0% 1.00 0.662
Soap is available 41 (91%) 38 (84%) 7% 1.89 0.261 11 (24%) 9 (20%) 4% 1.29 0.400

In both camps, there were a variety of difficulties which prevented mothers from sometimes washing their hands (Table 3). However, there were no substantial differences in the difficulties reported by doers and non-doers.

Table 3. Difficulties which hinders the mothers from washing their hands for both doers and non-doers in the two camps.

Camp 1 Camp 2
Participant Responses Doers Non-Doers Difference Odds ratio P value Doers Non-Doers Difference Odds ratio P value
What makes it difficult for you to wash your hands with soap at the five critical times each day?
The environment is dirty and uncomfortable 13 (29%) 7 (16%) 13% 2.21 0.102 9 (20%) 16 (36%) -16% 0.45 0.079
Hot weather and lack of electricity cause people to be sweaty 9 (20%) 11 (24%) -4% 0.77 0.400 26 (58%) 25 (56%) 2% 1.09 0.500
Soap is unavailable or affordable 8 (8%) 10 (22%) -4% 0.76 0.396 21 (47%) 25 (56%) -9% 0.70 0.264
Quality of water is poor 0 (0%) 1 (2%) -2% 0.00 0.500 25 (56%) 21 (47%) 9% 1.43 0.264
There is not enough water 1 (2%) 0 (0%) 2%   0.500 5 (11%) 6 (13%) -2% 0.81 0.500
Not enough space in the bathroom and the kitchen 1 (2%) 0 (0%) 2%   0.500 4 (9%) 6 (13%) -4% 0.63 0.370
Poor design of the handwashing facilities 2 (4%) 6 (13%) -9% 0.30 0.133 2 (4%) 1 (2%) 2% 2.05 0.500
Our handwashing facilities are shared 1 (2%) 4 (9%) -7% 0.23 0.180 0 (0%) 0 (0%) 0%  - 1.000
The water is hot 4 (9%) 5 (11%) -2% 0.78 0.500 0 (0%) 0 (0%) 0%   1.000
There is no privacy 3 (7%) 2 (4%) 2% 1.54 0.500 4 (9%) 2 (4%) 4% 2.10 0.338
The living environments are overcrowded 1 (2%) 4 (9%) -7% 0.23 0.180 0 (0%) 0 (0%) 0%   1.000
The handwashing facilities are far away 2 (4%) 2 (4%) 0% 1.00 0.692 0 (0%) 1 (2%) -2% 0.00 0.500
Hand washing facilities are damaged or broken. 0 (0%) 0 (0%) 0% 1.54 0.500 0 (0%) 4 (9%) -9% 0.00 0.058
Mental health challenges 1 (2%) 1 (2%) 0% 1.00 0.753 0 (0%) 2 (4%) -4% 0.00 0.247

There were no significant differences in the difficulties mentioned by doers and non-doers in relation to handwashing. Participants in C2 typically listed a greater number of difficulties than participants in C1. In both camps participants reported difficulties related to the hot weather, the cleanliness of the broader environment, a lack of privacy and mental health challenges. Some difficulties were more pronounced in C1. For example, participants reported that the water for handwashing was hot, the handwashing facilities were shared and too far away, and that the living environment was overcrowded. In contrast, the issues predominately reported in C2 included the quantity and quality of water, a lack of space in bathrooms and kitchens, and broken or damaged handwashing facilities.

Perceived positive consequences

Participants cited many positive consequences of handwashing (see Table 4). The majority of women in both sites said that the main positive consequence of handwashing with soap was the removal of dirt and the prevention of disease. In C1 both of these beliefs were actually more common among non-doers. For example, non-doers were 18% more likely than doers to report that getting rid of dirt was a key advantage of handwashing (p = 0.042). The third most commonly mentioned benefit was that handwashing could contribute to feeling more psychologically relaxed. Women also said that handwashing allows them to keep their children healthy and protected from disease and that it helps them feel more attractive.

Table 4. Comparison of the responses of doers and non-doers in each camp regarding the positive consequences of handwashing.

Camp 1 Camp 2
Participant Responses Doers Non-Doers Difference Odds ratio P value Doers Non-Doers Difference Odds ratio P value
What are the advantages of washing your hands with soap at the five critical times each day?
To get rid of dirtiness 30 (67%) 38 (84%) -18% 0.37 0.042* 42 (93%) 42 (93%) 0% 1.00 0.662
To get rid of germs and disease 39 (87%) 37 (82%) 4% 1.41 0.386 40 (89%) 38 (84%) 4% 1.47 0.379
To feel more relaxed psychologically 11 (24%) 10 (22%) 2% 1.13 0.500 7 (16%) 5 (11%) 4% 1.47 0.379
To prevent food from being contaminated 2 (4%) 5 (11%) -7% 0.37 0.217 1 (2%) 0 (0%) 2% 0.00  0.500
To look and smell good or improve my personal image 1 (2%) 2 (4%) -2% 0.49 0.500 0 (0%) 3 (7%) -7% 0.00 0.121
To improve my child’s health 2 (4%) 4 (9%) -4% 0.48 0.338 0 (0%) 1 (2%) -2% 0.00 0.500
To prevent insects, lice and flies 1 (2%) 0 (0%) 2%  2.05 0.500 2 (4%) 1 (2%) 2% 2.05 0.500

Perceived negative consequences

The majority of women in both camps did not think that there were any negative consequences of handwashing with soap. In C2, non-doers were 18% more likely than doers to report that they did not face any negative consequences from handwashing with soap (doers = 80%, non-doers = 98%, p = 0.008) while in C1 the reverse was true with doers 9% more likely to perceive there to be no negative consequences of handwashing (doers = 91%, non-doers = 82%, p = 0.176). The negative consequences related to dermatological consequences, with a total of 15 people across both sites reporting cracked or irritated hands and one other person feeling that handwashing caused their skin to become lighter in colour.

Social norms

In general, mothers in both sites reported that the people around them approved of them washing their hands with water and soap at the five critical times. However, a total of 18 people (20%) across both sites were not sure what other people thought about handwashing and 25 others (28%) thought people disapproved of regular handwashing with soap. In C1, 17 participants(38%) felt that their neighbours sometimes disapproved of them regularly washing their hands, while only one person (2%) shared this belief in C2. Doers in C1 appeared to receive substantial support from their mothers, with doers being 16% more likely to report this than non-doers (p-value = 0.015). In both camps, most of the mothers said that they relied on their own motivation to wash their hands, rather than the social approval of others. Table 5 describes the participants’ responses on social norms.

Table 5. Comparison of the doers and non-doers in each camp regarding perceived social norms.
Camp 1 Camp 2
Participant Responses Doers Non-Doers Difference Odds ratio P value Doers Non-Doers Difference Odds ratio P value
Who are the people that would approve of you washing your hands with soap at the five critical times each day?
I do it for myself 39 (87%) 41 (91%) -4% 0.63 0.370 42 (93%) 42 (93%) 0% 1.00 0.662
My mother 8 (18%) 1 (2%) 16% 9.51 0.015* 1 (2%) 1 (2%) 0% 1.00 0.753
My husband 6 (13%) 9 (20%) -7% 0.62 0.286 5 (11%) 1 (2%) 9% 5.50 0.101
Religious leaders 0 (0%) 2 (4%) -4% 0.00 0.247 0 (0%) 0 (0%) 0%   1.000
Who are the people that would disapprove of you washing your hands with soap at the five critical times each day?
No one 35 (78%) 33 (73%) 4% 1.27 0.403 44 (98%) 45 (100%) -2% 0.00 0.500
Neighbours 7 (16%) 10 (22%) -7% 0.64 0.296 1 (2%) 0 (0%) 2% 0.00 0.500

Perceived access

In both camps, the majority of participants said that accessing sufficient soap and water for handwashing was somewhat difficult or very difficult (Table 6), with residents of C2 (65 people in C2 compared to 39 in C1) and non-doers (p-value C1 = 0.76, p-value C2 = 0.90) being more likely to report difficulty.

Table 6. Comparison of the doers and non-doers in each camp regarding the perceived access to soap and water.

Camp 1 Camp 2
Participant Responses Doers Non-Doers Difference Odds ratio P value Doers Non-Doers Difference Odds ratio P value
How difficult is it to get the soap and water you need to wash your hands at the five critical times each day?
Very difficult 18 (40%) 21 (47%) -7% 0.76 0.335 32 (71%) 33 (73%) -2% 0.90 0.500
Somewhat difficult 15 (33%) 13 (29%) 4% 1.23 0.410 10 (22%) 11 (24%) -2% 0.88 0.500
Not difficult at all 11 (24%) 10 (22%) 2% 1.13 0.500 2 (4%) 1 (2%) 2% 2.05 0.500

Cues to action

In both camps, non-doers were more likely than doers to report that it was sometimes difficult to remember to wash their hands with water and soap at the five critical times (p-value C1 = 0.045, p-value C2 = 0.204). However, most of the mothers experienced no difficulty with remembering to wash their hands as shown in Table 7.

Table 7. Comparison of the doers and non-doers in each camp regarding the cues to action.

Camp 1 Camp 2
Participant Responses Doers Non-Doers Difference Odds ratio P value Doers Non-Doers Difference Odds ratio P value
How difficult is it to remember to wash your hands with soap at the five critical times each day?
Very difficult 1 (2%) 0 (0%) 2%   0.500 0 (0%) 1 (2%) -2% 0.00 0.500
Somewhat difficult 2 (4%) 8 (18%) -13% 0.22 0.045* 6 (13%) 10 (22%) -9% 0.54 0.204
Not difficult at all 42 (93%) 37 (82%) 11% 3.03 0.098 39 (87%) 34 (76%) 11% 2.10 0.141

Perceived risk

Table 8 describes participant perceptions of perceived vulnerability to diarrhoea, perceived severity of diarrhoea and the action efficacy of handwashing. Participants in C1 perceived themselves to be at much greater risk of diarrhoea than participants in C2, with 36 women in C1 reporting that they felt that their child was likely to get diarrhoea in the next three months, compared to just 12 in C2. Doers in both camps were also more likely to perceive their children as being susceptible to diarrhoea. For example, doers in C1 were 2.94 times more likely than non-doers to say that it was ‘somewhat likely’ that their children would get diarrhoea in the coming months (p-value = 0.037), while non-doers in C2 were 2.7 times more likely than doers to think that it was not at all likely that their children would get diarrhoea (p-value = 0.017). In C1 most doers felt that diarrhoea was a ‘very serious problem’ and were 2.92 times more likely to give this response when compared with non-doers (p-value = 0.02). In C2 this difference was not observed. The perceived action efficacy was high in C2 with both doers and non-doers believing that handwashing with soap at critical times can prevent diarrhoea (83% overall). It was considerably lower in C1 (61% overall) and in this camp doers were more likely to doubt the action efficacy of handwashing against diarrhoea.

Table 8. Comparison of the doers and non-doers in each camp regarding the perceived risk.

Camp 1 Camp 2
Participant Responses Doers Non-Doers Difference Odds ratio P value Doers Non-Doers Difference Odds ratio P value
How likely is it that your child will get diarrhoea in the coming three months?
Very likely 17 (38%) 19 (42%) -4% 0.83 0.415 8 (18%) 4 (9%) 9% 2.22 0.176
Somewhat likely 14 (31%) 6 (13%) 18% 2.94 0.037* 18 (40%) 11 (24%) 16% 2.06 0.088
Not likely at all 14 (31%) 20 (44%) -13% 0.56 0.138 19 (42%) 30 (67%) -24% 0.37 0.017*
How serious would it be if your child got diarrhoea?
Very serious problem 36 (80%) 26 (58%) 22% 2.92 0.020* 33 (73%) 34 (76%) -2% 0.89 0.500
Somewhat serious problem 5 (11%) 11 (24%) -13% 0.39 0.083 9 (20%) 5 (11%) 9% 2.00 0.192
Not serious at all 4 (9%) 6 (13%) -4% 0.63 0.370 3 (7%) 6 (13%) -7% 0.46 0.242
How likely is it that your child will suffer from diarrhoea if you wash your hands with soap at the five critical times each day?
Very likely 4 (9%) 0 (0%) 9%   0.058 0 (0%) 1 (2%) -2% 0.00 0.500
Somewhat likely 17 (38%) 13 (29%) 9% 1.49 0.251 7 (16%) 7 (16%) 0% 1.00 0.614
Not likely at all 24 (53%) 31 (69%) -16% 0.52 0.097 38 (84%) 37 (82%) 2% 1.17 0.500

Religion, culture and policy

In both camps, no significant difference existed between the doers and non-doers regarding religion, culture and policy. The vast majority of participants in both camps did not believe that it was ‘God’s will’ that determined whether children got diarrhoea (94% in C1 and 92% in C2, p = 0.5 in both camps). All participants in both camps said that there were no cultural taboos that prevented handwashing. In C1 non-doers were more likely to report that there were community laws or rules in place to encourage handwashing (doers = 31, non-doers = 39, p-value = 0.037). Specifically, they referred to the role of non-governmental organizations in promoting handwashing. Doers in C1 were 2.4 times more likely to report that no such rules existed (p-value = 0.037). In C2 there were no significant differences between doers and non-doers; however, participants in this camp were more likely to report the absence of any community rules (rules present = 40%, rules absent = 60%).

Discussion

This study used the Barrier Analysis method to explore the determinants affecting handwashing with soap among IDP populations in two camps in KRI. Here we summarise the findings according to the classification of doers and non-doers and compare behaviour in the two camps. We also reflect on the Barrier Analysis method, highlighting the strengths and weaknesses of the approach.

Summary of the findings

Our study identified a surprising level of homogeneity between the reported behaviour, beliefs and perceptions of doers and non-doers in relation to handwashing with soap. Doers and non-doers both felt able to wash their hands (self-efficacy) and believed that it would prevent them getting diarrhoea (action efficacy). Both groups believed that religion and culture had minimal effects on handwashing and both groups described similar difficulties, benefits, and levels of access to soap and water. These similarities are likely to be a reflection of the fact that the populations and physical environment within each camp were homogeneous.

Generally, participants across both camps felt that there were minimal negative consequences of handwashing. However, doers in C1 were more likely to report skin irritations, while in C2 this was more common among non-doers. Participants cited a range of benefits associated with handwashing but interestingly non-doers, particularly in C1, were more likely to report that the primary benefit was the removal of dirt from hands (p-value C1 = 0.042). One possible explanation for this finding is that non-doers may be more likely to reactively wash their hands when hands are visibly dirty rather than at critical times. There is evidence from others studies about visible dirt acting as a key motivator for handwashing with soap.[12,31]

Most participants said that they were self-motivated to wash their hands and did not require support from others. However, doers in C1 were more likely than non-doers to receive social approval from their mothers to practice handwashing with soap (p-value = 0.015). This finding was not replicated in C2. Most participants said they found handwashing easy to remember. However, non-doers in both camps were more likely to report challenges remembering to always wash their hands with soap at critical times. This finding was particularly pronounced in C1 (p-value = 0.045). Doers were more likely to feel that their children were susceptible to diarrhoea (p-value C1 = 0.037, p-value C2 = 0.017). Doers in C1 were more likely than non-doers to describe diarrhoea as a ‘very serious problem’ (p-value = 0.02), but no such difference was observed in C2. Doers in C1 were more aware of ‘policies’ which supported handwashing with soap, specifically citing the role of non-governmental organizations in promoting handwashing (p-value = 0.037). No such difference was observed in C2.

Several of our findings may at first seem to run counter to logical assumptions about behaviour. For example, in C2 non-doers were more likely to report that there were no negative consequences to handwashing. One explanation for this finding is that since non-doers wash their hands less frequently they may have also not encountered some of the negative consequences that doers reported (e.g. skin irritation). In C1 doers doubted the action efficacy of handwashing more than non-doers. One explanation for this finding might be that doers, as regular hand-washers, realise that handwashing is important but not sufficient to block all routes of diarrhoeal disease transmission. Alternatively, it may be that these findings occurred by chance.

The similarity of the findings is interesting given that the populations in the two camps were quite different–people came from different geographical locations, were from different cultures, had different religions and had been displaced for different periods of time. There was also a difference in the quality of WASH services provided in the two camps, with C2 having objectively better conditions (namely because WASH facilities were not shared). Despite having objectively better conditions, participants in C2 reported a greater number of barriers to handwashing. This may be because at the acute stage of a crisis (as in C1) people are relieved to receive basic WASH provisions. However, when populations are displaced for an extended period of time (as in C2) they begin to tire of WASH conditions that are substantially poorer than what they were accustomed to prior to displacement. Overall there were more pronounced differences between doers and non-doers in C1 than in C2. This may indicate that camp environments tend to create new emergent norms [32]. That is to say that when people live in condensed living environments for an extended period of time, their behaviour and beliefs become more similar.

The findings highlighted in this study are not dissimilar to studies which have explored the determinants of handwashing behaviour in non-emergency settings. However, there are a few notable exceptions to this. In both camps, the trauma experienced by the populations appeared to affect their behaviour. Some people said that their mental health impaired their ability to wash their hands with soap while others said that handwashing helped them to ‘feel more relaxed psychologically’. Studies in this region have estimated that almost all Yazidi survivors exhibit symptoms of psychiatric disorders [3335]. Anecdotal evidence indicates rates are likely to be similarly high among Arabs displaced from Mosul [36,37]. It is likely that mental health may be a factor that influences handwashing behaviour in other crisis-affected contexts yet this was unable to be sufficiently documented through the Barrier Analysis method since there were no specific questions exploring this.

Secondly, our findings suggest that people in displacement camps may be more likely to attribute handwashing challenges to factors in the external environment, beyond their control. When asked about handwashing difficulties, people reported being disgusted by the camp environment, describing it as ‘dirty,’ ‘overcrowded’ and ‘uncomfortable.’ They also described feeling motivated to wash their hands because of their increased sweatiness and exposure to the summer heat (they were used to hot temperatures prior to displacement but were now much more directly affected by the weather due to living in tented shelters). People were also dissatisfied with the quality of WASH services in the camp. Frustration with the distance to facilities and the appropriateness of the design of handwashing facilities is likely to be less commonly reported in non-emergency situations where populations are responsible for purchasing and building their own handwashing stations.

Our findings suggest that behavioural interventions targeted at IDPs within these contexts should try to increase perceived social support for handwashing, provide cues to trigger behaviour, and increase perceived risk in relation to both susceptibility and severity. Providing a more dermatologically-friendly soap might help to reduce the perceived negative consequences of handwashing. Improving the design and location of handwashing facilities so that they are more acceptable and convenient is likely to reduce perceived barriers to handwashing practice. Improving handwashing facilities [3841] and adding behavioural cues [4244] has been demonstrated to work in other studies in stable settings. Increasing risk should be done with care so as not to create unintended consequences [45]. There is some evidence from other crises that heightening fear only has short term benefits on handwashing behaviour [14,46].

Reflections on the barrier analysis approach

The Barrier Analysis approach proved feasible to do in an emergency context as it was conducted in both sites, in 14 days, by two staff. The appeal of the approach to practitioners is its ability to translate qualitative responses into quantitative data. Its reliance on ‘statistically significant’ differences helps practitioners who are new to the field of behaviour change to pin-point which barriers to focus on.

However, in this study it was this perceived strength, that limited the generation of meaningful insights about behaviour. The standard Barrier Analysis approach is perhaps less suited to settings with high homogeneity (both in terms of population characteristics and the physical settings/access to resources) or where handwashing rates are already relatively high. This is because it is powered to detect major differences in the determinants of behaviour. Our results indicate that in Middle-Eastern camp settings differences between doers and non-doers are likely to be more subtle.

We followed the statistical analysis process recommended by the Barrier Analysis approach. However, we feel there are several limitations of this. Firstly, we feel that Fisher’s exact test may be more appropriate than a Pearson chi-square test because of the small sample sizes recommended for Barrier Analysis surveys [47]. Secondly, some of the standard Barrier Analysis question collect ordinal data (See Tables 6,7 and 8). It would be more appropriate to use a Kendall rank correlation coefficient to assess these questions where there are two ordinal-scaled variables[48]. Even with limitations of the statistical methods recommended by the Barrier Analysis method, there were relatively few ‘statistically significant’ differences between doers and non-doers in our results. A standard analysis of these results would suggest that there were minimal changes that needed to be made to improve handwashing behaviour in this context. The reliance of the Barrier Analysis method on ‘statistically significant’ results is also inconsistent with current thinking on statistical interpretation [49] and may down-play the value of the full set of open-ended responses which in this case were rich, varied and programmatically relevant.

We may have observed minimal differences between doers and non-doers because this population was highly exposed to hygiene promotion activities, therefore their responses to self-reported questions may have been affected by social desirability bias. This is a widely recognised limitation of self-reported measures of assessing handwashing behaviour [50,51]. This potential bias, further justifies the need to combine the Barrier Analysis with other methods for exploring behaviour such as proxy measures, monitors, sticker diaries, observation or script-based covert recall [50,52,53]. It is also possible that Barrier Analyses are more appropriate for behaviours where there is a clear way of measuring whether people are doers and non-doers (such as smoking cessation [54]). For a routine behaviour like handwashing with soap, the dichotomy between doers and non-doers may be false—with any given individual remembering to practice on some critical occasions and not on others.

We also found that the questions relating to norms, religion, culture and policy were too narrow, given that they are each assessed with a single closed answer question. We feel that this may have prevented deeper learning about these topics, which are likely to be even more critical in crisis contexts. Future application of Barrier Analyses in conflict-affected settings might consider additional questions on these topics and drawing on a broader literature of norms assessment [55,56].

During our surveys, people often wanted to talk about topics other than handwashing. People often answered the set questions but then went on to share their experiences of the conflict or discuss the broader challenges they faced in the camp. These patterns in participant responses raise some ethical concerns about the appropriateness of very narrow assessment tools in crisis-affected contexts. While Barrier Analysis provides a feasible, rapid way of assessing behaviours that are of interest to public health practitioners, these behaviours may be of relatively low priority to crisis-affected populations given their current predicament. If multiple, similar types of assessments were to be done, as they often are in a crisis, this may cause crisis-affected populations to develop a sense of frustration with the humanitarian system. If others are planning to use the Barrier Analysis approach, then they should plan to locate the method within a broader community dialogue and have in place referral mechanisms to address unanticipated topics that may arise while conducting the questionnaire.

Our study may have been limited by the fact that all 180 questionnaires were conducted by just two people. Larger teams are typically involved in the Barrier Analysis data collection and coding process. While we do not feel this substantially affected the data quality, a larger team may have reduced interviewer fatigue and lead to a richer discussion between team members during the thematic analysis.

Conclusion

Implementing the Barrier Analysis approach in post-conflict, camp settings was feasible and highlighted some behavioural barriers that could be addressed through hygiene programming. The homogeneity of our results, within and between the two camps, may indicate that routine behaviours like handwashing tend to vary less in camp settings where populations have been through similar experiences and have access to the same physical infrastructure. Future work in camp-based, post-conflict settings could benefit from combining rapid assessment tools like Barrier Analysis with other more holistic qualitative methods that rely less on self-reported behaviour and which are more sensitive to the diverse needs of displaced people.

Supporting information

S1 File. Barrier analysis questionnaire.

(DOCX)

Acknowledgments

We would like to thank Basima Ahmed who assisted with the data collection and the team at Action Contre la Faim in Iraq who provided substantial support in terms of logistics, security and office space. We would also like to thank all the people who participated in this research and gave generously of their time.

Data Availability

The Barrier Analysis Questionnaire used during this study is attached as a supplementary material. All data analysis files are available from the Figshare database (URL: https://doi.org/10.6084/m9.figshare.8152751.v1)

Funding Statement

This reserach was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the study authors and do not necessarily reflect the views of USAID or the United States Government. A grant from the Office of U.S. Foreign Disaster Assistance was recieved by SW (award number AID-OFDA-G-16-00270). Funder website: https://www.usaid.gov/who-we-are/organization/bureaus/bureau-democracy-conflict-and-humanitarian-assistance/office-us. The funders played no role in the study design, data collection, analysis, decision to publish or preperation of the manuscript.

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Decision Letter 0

Ginny Moore

22 Jan 2020

PONE-D-19-25323

The determinants of handwashing behaviour among internally displaced people in two camps in the Kurdistan Region of Iraq

PLOS ONE

Dear Ms White,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I am returning your manuscript with three reviews. As you will see, all three reviewers highlight the need for research of this type to be carried out. However, all three express concerns regarding the methodology - specifically the identification and classification of "doers" and "non-doers", the data analysis - specifically the statistical tests used and the interpretation of the data. More detail regarding the camps (e.g. selection process; condition and NGO activities) and how this may have impacted behaviour is also requested. The concept of "emergent norms" is briefly discussed; was the length of time each mother had lived within the camp documented - did this differ between "doers" and "non-doers"? 

Whilst major revision of your manuscript is required, the reviewers acknowledge that studies on handwashing behaviour in humanitarian settings are lacking and so I encourage you to give their comments and suggestions due consideration. Please note, that on resubmission (if you choose to do so), the manuscript will have to go through the second round of review including if deemed necessary, a statistical review.

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: TECHNICAL FEEDBACK

1. It is good to see a study on handwashing in humanitarian settings. The authors are well justified in their contention that this kind of research is needed.

2. The major technical limitation of the study lies with the identification of doers and non-doers. The authors report that “The screening process used a combination of self-reported handwashing behaviour and proxy measures of handwashing behaviour (such as the observed presence of used soap at the handwashing facility).” Self-reported handwashing is notoriously overreported:

https://journals.lww.com/jhqonline/Abstract/2007/07000/Reliability_and_Validity_of_Hand_Hygiene_Measures.5.aspx

Even direct observation of handwashing can overestimate actual handwashing: http://www.ajtmh.org/content/journals/10.4269/ajtmh.2010.09-0763

Script-based covert recall may be an alternative: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0136445

In this setting, proxy measures themselves may be inaccurate, and soap may be more available in a humanitarian setting than it would be normally.

Therefore, the study does not convincingly measure handwashing in a valid manner, and this throws into doubt the validity of classification of study participants as doers and non-doers.

3. “Perceived social norms - The perception that people important to an individual think that he/she should wash their hands with soap. Note that in theories such as the Focus Theory of Normative Conduct, this is the definition of injunctive norms. See: Cialdini, R.B.; Reno, R.R.; Kallgren, C.A. (1990). "A focus theory of normative conduct: Recycling the concept of norms to reduce littering in public places". Journal of Personality and Social Psychology. 58 (6): 1015–1026. doi:10.1037/0022-3514.58.6.1015.

4. Wrong statistical methods. In Tables like Table 8, the outcome or dependent variable “How likely is it that your child will get diarrhoea in the coming three months?” is an ordinal variable (See https://en.wikipedia.org/wiki/Ordinal_data for a definition) with three ordered responses. Appropriate measures of correlation include Kendall’s Tau-B, see https://en.wikipedia.org/wiki/Ordinal_data#Bivariate_statistics. It is inappropriate and incorrect to calculate a p-value for each row of the table. One single p-value and measure of association should be calculated with a statistical test like Kendall’s Tau-B. The same applies to Table 6 and 7.

5. In the absence of accompanying qualitative interview and observation data, it is difficult to draw any conclusions about why people do or do not wash their hands.

MINOR SPELLING AND GRAMMAR ISSUES

1. Please do a spell-check e.g. there are three errors here on the first page: “This [research] was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the study authors and do not necessarily reflect the views of USAID or the United States Government. A grant from the Office of U.S. Foreign Disaster Assistance was [received] by SW (award number AID-OFDA-G-16- 00270). Funder website: https://www.usaid.gov/who-we- are/organization/bureaus/bureau-democracy-conflict-and-humanitarian- assistance/office-us. The funders played no role in the study design, data collection, analysis, decision to publish or [preparation] of the manuscript.”

2. Line 289 – delete ‘of’ or reword that part of sentence

3. Line 388 – change subtler to more subtle

4. Line 397 – remove comma

Reviewer #2: Thank you for this interesting work. Overall, this is well written and useful for the humanitarian sector.

A good edit of the intro, methods, and results is needed; I thought the discussion was particularly well written and organized.

Something that I felt was missing was the discussion of WASH activities in the camps and previous/current hygiene promotion. NGO presence and activities need to be explained. By not describing NGO activities, the assumption is that NGO activities, promotion or distribution of materials or cash/vouchers have no impact on actions - I believe that to be rather significant and must be addressed.

Differences were mentioned briefly about the camps, but more analysis should be presented. If the different camps are actually similar, would combining the data sets provide a better opportunity for significant results.

How the camps were selected from what I would assume to be be dozens of camps needs to be explained.

Within the results there were several interesting findings (significant or not) that would be against logical assumptions, i.e. non-doers thought washing their hands would make them safer compared to doers (or something along those lines). While not significant, some explanation should be given or rationalized, especially since it seemed to occur several times.

Detailed comments:

Line 52-3: Strong statement. Please reference. Limited water availability or lack of soap could also be reasons. 

Line 64: Please be explicit about 'this research gap'

Methods: Please explain how these camps were selected, assuming this is a clear rationale. 

Line 83: .'..still experiencing trauma' - While this is likely the case, please avoid sweeping statements that are beyond the research.Line 84: Please be more clear on the camp conditions meeting the Sphere standards and temperature is not a Sphere standard. This paragraph should be revised and focused on camp conditions and population demographics. The high standard of living and accustomed to flush toilets is useful, but taking away electronics etc. is not relevant. 

Line 100: Who (what organization) was doing hygiene promotion? The approach should be described and is an obvious factor in beneficiaries hygiene activities. One camp needing to buy soap could also be a huge factor compared to 'in-kind' distributions. 

Line 118-122: These sentences are not relevant

Line 144: Some words required brainstorming - how can you be sure the beneficiaries understood the questions?   Line 193: So, someone describing 2 times washing their hands would be a non-doer? Or someone who described washing each of th3 5 time points, but ran out of soap would also be a non-doer? 

Line 210: Please state the statistics with p-value.

Results: Are the camps comparable? Was analysis conducted to determine they were similar?

Result tables should be better organized to highlight that results are by camp. 

Table 4: the only significant finding thus far is that non-doers state reasons why more than doers. Please explain or discuss. 

Line 252 Social Norms - results are presented differently. Please be consistent and give percentages over absolute numbers because its not clear what the same size is. 

Line 292 table: Doers say child very likely to get sick if they wash at the 5 critical times. Things like this are odd - some explanation should be given. 

Line 299: Please give stats. 

Line 319: God's will being a reason people get sick is a pretty large factor. 

Line 336: To me, it seemed like there were little similarities. No topic was significant in both camps correct?

Reviewer #3: This paper provides a practical assessment of the determinants of handwashing behaviour among internally displaced women who had a child under the age of five in two camps in the Kurdistan Region of Iraq . This is a topic for which there is a substantial need for research, and it is encouraging to see the authors taking on the challenge of contributing to this gap in evidence. Generally speaking, this is a very clear paper that I would recommend for publication with some revisions and additions.

The title of the does not represent the study population. The study team administered the questionnaires to “women who had a child under the age of five” but authors used “internally displaced people” in the title. Authors should change the study title to make it clear. The introduction could be a bit more comprehensive in terms of contextualizing the research based on existing evidence. The methods section is straightforward but should add some missing references. The results/discussion section is solid, though Table 2-8 in particular had 2 unnecessary column and should be removed from each table. The conclusion is quite vague and should be bolstered with more specific recommendations based on the results of this study.

Below I have provided a few points which should be addressed:

1. The introduction could be a bit more comprehensive in terms of contextualizing the research based on existing evidence.

2. In the abstract in line 38, the terminology "demographics" is used. It would be good to use “socio-demographics”.

3. Line 66-68: Authors should remove this "In turn, it is hoped that an increased understanding of behavioural determinants will allow humanitarians to design more acceptable and effective handwashing promotion programmes "

4. Line 82-83: The authors should provide reference for this “All participants had been exposed to extreme violence in the past three years and many were still experiencing trauma at the time of this research”.

5. Line 90-91: The authors should provide reference (s) for this “Many of the residents had come from urban or peri-urban areas and were used to a relatively high standard of living prior to the conflict.

6. The title of the does not represent the study population. The study team administered the questionnaires to “women who had a child under the age of five” (Line 149) but authors used “internally displaced people” in the title. Authors should change the title.

7. Line 173: “to maintain quality and identify any missing data” Authors should make it clear how they maintain the quality of data and what they actually had done it they could identify any missing data.

8. Table 2-8 had 2 unnecessary column and should be removed from each table.

9. The conclusion is quite vague and should be bolstered with more specific recommendations based on the results of this study.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PLoS One. 2020 May 8;15(5):e0231694. doi: 10.1371/journal.pone.0231694.r002

Author response to Decision Letter 0


28 Jan 2020

We thank the reviewers for their feedback and feel that their recommendations have enhanced the manuscript. We have edited the manuscript to address the reviewers’ concerns and responded to each comment point-by-point below.

We have submitted a clean copy of the manuscript and one with tracked changes.

Editor Comments:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We have revised the formatting of the document to be more consistent ant with the PLOS ONE journalistic style. Specifically we have changed the section headers and the Supplementary information file names.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Additionally, please include upon how many participants the pre-testing of the questionnaire occurred.

Response: There was only one research tool used for this work. This was already attached as a supplementary information file. This questionnaire follows the standard format for Barrier Analysis surveys of handwashing behaviour.

3. Please refer to any post-hoc corrections for multiple comparisons you made during your statistical analyses. If these were not performed please justify why.

Response: No post-hoc corrections were made for multiple comparisons.

4. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 7 in your text; if accepted, production will need this reference to link the reader to the Table.

Response: There was an error in the numbering of this table and this has now been corrected in the text.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information

Response: We have changed the in text reference to this file and added full captions at the end of the manuscript.

6. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript.

Response: Details about our ethics and consent process are included in the Methods section already and have been removed from the end of the manuscript.

Review 1 comments:

1. It is good to see a study on handwashing in humanitarian settings. The authors are well justified in their contention that this kind of research is needed.

Response: We thank the reviewer for their kind words.

2. The major technical limitation of the study lies with the identification of doers and non-doers. The authors report that “The screening process used a combination of self-reported handwashing behaviour and proxy measures of handwashing behaviour (such as the observed presence of used soap at the handwashing facility).” Self-reported handwashing is notoriously overreported:

https://journals.lww.com/jhqonline/Abstract/2007/07000/Reliability_and_Validity_of_Hand_Hygiene_Measures.5.aspx

Even direct observation of handwashing can overestimate actual handwashing: http://www.ajtmh.org/content/journals/10.4269/ajtmh.2010.09-0763

Script-based covert recall may be an alternative: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0136445

In this setting, proxy measures themselves may be inaccurate, and soap may be more available in a humanitarian setting than it would be normally.

Therefore, the study does not convincingly measure handwashing in a valid manner, and this throws into doubt the validity of classification of study participants as doers and non-doers.

Response: We thank the reviewer for raising these limitations and agree with their concerns. We already highlighted the limitations of self-reported measures in the discussion (line 403) but we have revised this to make it clearer and some of the alternative measures they suggest. Note also that the purpose of this manuscript was to assess the BA method as a commonly used assessment technique, not necessarily as a method we endorse. Self-report is still the only behavioural measure included in standard BA surveys.

3. “Perceived social norms - The perception that people important to an individual think that he/she should wash their hands with soap. Note that in theories such as the Focus Theory of Normative Conduct, this is the definition of injunctive norms. See: Cialdini, R.B.; Reno, R.R.; Kallgren, C.A. (1990). "A focus theory of normative conduct: Recycling the concept of norms to reduce littering in public places". Journal of Personality and Social Psychology. 58 (6): 1015–1026. doi:10.1037/0022-3514.58.6.1015.

Response: We recognise this terminology discrepancy and that there is substantial disagreement on terminology to describe behavioural determinants in general. Our use of the term ‘perceived social norms’ in this manuscript is based on the definition of terms laid out in the BA guide. We have added into the discussion that we feel this is a particularly narrow conception of norms and suggested that future users refer to broader literature on this subject.

4. Wrong statistical methods. In Tables like Table 8, the outcome or dependent variable “How likely is it that your child will get diarrhoea in the coming three months?” is an ordinal variable (See https://en.wikipedia.org/wiki/Ordinal_data for a definition) with three ordered responses. Appropriate measures of correlation include Kendall’s Tau-B, see https://en.wikipedia.org/wiki/Ordinal_data#Bivariate_statistics. It is inappropriate and incorrect to calculate a p-value for each row of the table. One single p-value and measure of association should be calculated with a statistical test like Kendall’s Tau-B. The same applies to Table 6 and 7.

Response: We followed the statistical methods recommended by the Barrier Analysis. We agree with the reviewer that there are some important limitations of these. Rather than re-do the analysis post-hoc we have decided to describe these limitations in the discussion.

5. In the absence of accompanying qualitative interview and observation data, it is difficult to draw any conclusions about why people do or do not wash their hands.

Response: We agree that there are limitations with using this method alone. However, we also saw merit in testing this method. In our case, this BA study was done alongside other qualitative work (including observation) which is going to be reported separately. We felt that if we are going to persuade humanitarians to use more time consuming and complex methods then we needed to know the value add of these in comparison with the BA survey which is the status-quo.

MINOR SPELLING AND GRAMMAR ISSUES

1. Please do a spell-check e.g. there are three errors here on the first page: “This [research] was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the study authors and do not necessarily reflect the views of USAID or the United States Government. A grant from the Office of U.S. Foreign Disaster Assistance was [received] by SW (award number AID-OFDA-G-16- 00270). Funder website: https://www.usaid.gov/who-we- are/organization/bureaus/bureau-democracy-conflict-and-humanitarian- assistance/office-us. The funders played no role in the study design, data collection, analysis, decision to publish or [preparation] of the manuscript.”

2. Line 289 – delete ‘of’ or reword that part of sentence

3. Line 388 – change subtler to more subtle

4. Line 397 – remove comma

Response: We have gone through and made these specific changes as well as doing a general edit.

Reviewer 2 comments:

1. Thank you for this interesting work. Overall, this is well written and useful for the humanitarian sector. A good edit of the intro, methods, and results is needed; I thought the discussion was particularly well written and organized.

Response: We than the reviewers for their kind comments. WE have done a full read through to pick up on grammatical errors.

2. Something that I felt was missing was the discussion of WASH activities in the camps and previous/current hygiene promotion. NGO presence and activities need to be explained. By not describing NGO activities, the assumption is that NGO activities, promotion or distribution of materials or cash/vouchers have no impact on actions - I believe that to be rather significant and must be addressed.

Response: We have added some information about the nature of hygiene promotion in the study site description. Our study did not seek to measure the impact of existing NGO activities in relation to Hygiene Promotion and as such the survey was only done at one time-point. So we cannot draw a conclusion about the effectiveness of these particular activities in this context. However, these types of approaches have been widely used elsewhere and have not been able to realise substantial changes in behaviour.

3. Differences were mentioned briefly about the camps, but more analysis should be presented. If the different camps are actually similar, would combining the data sets provide a better opportunity for significant results.

Response: Although the camps were in the same geographical location they were quite different in terms of their populations, facilities, regulations, and the duration of displacement. The rationale for purposively selecting these camps was to see if behaviour different substantially in these two settings. Hence we have chosen not to combine the two sites.

4. How the camps were selected from what I would assume to be dozens of camps needs to be explained.

Response: The camps were purposively selected. We have added this along with the criteria used into the manuscript.

5. Within the results there were several interesting findings (significant or not) that would be against logical assumptions, i.e. non-doers thought washing their hands would make them safer compared to doers (or something along those lines). While not significant, some explanation should be given or rationalized, especially since it seemed to occur several times.

Response: We have now added a section on this in the discussion

6. Line 52-3: Strong statement. Please reference. Limited water availability or lack of soap could also be reasons.

Response: This statement is backed up with reference in the following sentence. A few sentences further on we also discuss the lack of access to water and soap as a barrier.

7. Line 64: Please be explicit about 'this research gap'

Response: Thanks for pointing out that this was unclear. WE have re-written this section to be more specific.

8. Methods: Please explain how these camps were selected, assuming this is a clear rationale.

Response: The camps were selected purposively based on a set of criteria. This has been added to the manuscript.

9. Line 83: .'..still experiencing trauma' - While this is likely the case, please avoid sweeping statements that are beyond the research.

Response: We have clarified that this was based on reports from participants and camp management.

10. Line 84: Please be more clear on the camp conditions meeting the Sphere standards and temperature is not a Sphere standard. This paragraph should be revised and focused on camp conditions and population demographics. The high standard of living and accustomed to flush toilets is useful, but taking away electronics etc. is not relevant.

Response: We have chosen to leave in this section on temperature and intermittent electricity because we feel it does provide a useful understanding of context. Temperature factors are known to affect handwashing behaviour (with hot weather more likely to make people feel sticky and dirty and cue handwashing).

11. Line 100: Who (what organization) was doing hygiene promotion? The approach should be described and is an obvious factor in beneficiaries hygiene activities. One camp needing to buy soap could also be a huge factor compared to 'in-kind' distributions.

Response: We have added that hygiene promotion was done by ‘international and local non-government organisations (NGOs) in conjunction with hygiene promoters from the camp population’. We do not feel it is necessary to name the organisations working there at this time. The fact that one camp no longer provided hygiene kit distributions was one of our reasons for selecting it. Observationally we noted that there was no shortage of soap in this camp however we do see differences in the results based on perceived affordability of soap in this camp.

12. Line 118-122: These sentences are not relevant

Response: We feel that this section is relevant as appraising the merits and limitations of the BA approach was a secondary aim of our work.

13. Line 144: Some words required brainstorming - how can you be sure the beneficiaries understood the questions?

Response: We have added that this was done through a focus group discussion. Although we didn’t describe this in depth, pour translation team came up with several possible terms initially. We then get members of the local population to define each of the terms in their own words and use them in a sentence. This helped us identify which terms would be most similar to the English version of the questionnaire. To be clear this was all done to arrive at the final Arabic and Kurdish questionnaire. A standard version of each question was used in the actual survey.

14. Line 193: So, someone describing 2 times washing their hands would be a non-doer? Or someone who described washing each of th3 5 time points, but ran out of soap would also be a non-doer?

Response: The questions asked in the screening are provided in full in the supplementary material. A person who could only state 2 occasions when hands should be washed (despite additional probing) would be classed as a non-doer. A person who could list more than 3 occasions for handwashing but who did not have soap and water at the handwashing facility was classified as a non-doer. Soap scarcity was not a major issue in this population, a larger barrier was hoarding soap or keeping it in the household so that it wouldn’t be stolen by others.

15. Line 210: Please state the statistics with p-value.

Response: This has been added.

16. Results: Are the camps comparable? Was analysis conducted to determine they were similar?

Response: As discussed in the paragraph beginning on line 372, the camps were intentionally different in terms of facilities and socio-demographic characteristics. However, we found quite a lot of similarities in their perceptions around handwashing behaviour. We also discuss key differences in this paragraph.

17. Result tables should be better organized to highlight that results are by camp.

Response: We have changed the formatting to making this clearer.

18. Table 4: the only significant finding thus far is that non-doers state reasons why more than doers. Please explain or discuss.

Response: There are several statistically significant findings, specifically:

• Non-Doers in C2 are more likely to think that there is no likelihood of their children getting diarrhoea in the next 3 months.

• Doers in C1 being more likely to think that there is somewhat of a likelihood of getting diarrhoea in the next 6 months.

• Non-doers in C1 being more likely to think that it is somewhat difficult to remember to wash hands at critical times.

• Doers in C1 were more likely to think that their mothers would approve of their handwashing.

• Non-doers in C1 were more likely to think that an advantage of handwashing was removing dirtiness from hands.

Each of these is described in the text we have also added a section explaining some of the more surprising findings.

19. Line 252 Social Norms - results are presented differently. Please be consistent and give percentages over absolute numbers because its not clear what the same size is.

Response: Thanks for picking up on this we have now added percentages to this section also.

20. Line 292 table: Doers say child very likely to get sick if they wash at the 5 critical times. Things like this are odd - some explanation should be given.

Response: We have added a section in the discussion where we discuss some of these unexpected findings.

21. Line 299: Please give stats.

Response: We have added the p-vlaue for the religion question. All other stats were already included in the written description.

22. Line 319: God's will being a reason people get sick is a pretty large factor.

Response: We agree with the reviewer’s point on this. We feel that this one question is insufficient to fully understand this determinant as we have mentioned in the discussion.

23. Line 336: To me, it seemed like there were little similarities. No topic was significant in both camps correct?

Response: We are a little unclear what the reviewer meant by this comment but the text on line 336 refers to a comparison between known determinants of handwashing in stable settings (this is what the Barrier Analysis was developed based on) and determinants that are either not accounted for in the BA survey or are not sufficiently accounted for in the BA survey but may be more important in crisis settings.

Reviewer 3 comments:

1. This paper provides a practical assessment of the determinants of handwashing behaviour among internally displaced women who had a child under the age of five in two camps in the Kurdistan Region of Iraq. This is a topic for which there is a substantial need for research, and it is encouraging to see the authors taking on the challenge of contributing to this gap in evidence. Generally speaking, this is a very clear paper that I would recommend for publication with some revisions and additions.

Response: We thank the authors for their kind comments.

2. The title of the does not represent the study population. The study team administered the questionnaires to “women who had a child under the age of five” but authors used “internally displaced people” in the title. Authors should change the study title to make it clear.

Response: We have changed the title to ‘The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq’

3. The introduction could be a bit more comprehensive in terms of contextualizing the research based on existing evidence.

Response: We have added some additional citations to the introduction. We have also added a section on determinant assessment in stable settings as a point of comparison. If there are additional further points the reviewer feels we should address in this section, then we would be willing to take this more specific feedback on board.

4. The methods section is straightforward but should add some missing references.

Response: We are not really sure what the reviewer was referring to here. We have already referenced our main method and included links to other similar approaches.

5. The results/discussion section is solid, though Table 2-8 in particular had 2 unnecessary column and should be removed from each table.

Response: It is not clear from the reviewer’s comment which columns they feel are unnecessary. We have not made any changes but are happy to do so with more clarity.

6. The conclusion is quite vague and should be bolstered with more specific recommendations based on the results of this study.

Response: We believe we have discussed the findings in detail. Indeed, other reviewers felt that our discussion was the strongest part of our manuscript. Specifically we already provide detail on the key opportunities for people working in this context and link this to broader literature.

7. In the abstract in line 38, the terminology "demographics" is used. It would be good to use “socio-demographics”.

Response: this has been changed

8. Line 66-68: Authors should remove this "In turn, it is hoped that an increased understanding of behavioural determinants will allow humanitarians to design more acceptable and effective handwashing promotion programmes "

Response: This has been removed.

9. Line 82-83: The authors should provide reference for this “All participants had been exposed to extreme violence in the past three years and many were still experiencing trauma at the time of this research”.

Response: We cannot provide a reference for this. This is based on our work in these settings. We have clarified this in the text.

24. Line 90-91: The authors should provide reference (s) for this “Many of the residents had come from urban or peri-urban areas and were used to a relatively high standard of living prior to the conflict.

Response: Again we do not have a reference for this nor do we feel it is necessary. As stated these IDPs came from Mosul and Sinjar respectively. Both were bustling, modern metropolises prior to the conflict.

25. Line 173: “to maintain quality and identify any missing data” Authors should make it clear how they maintain the quality of data and what they actually had done it they could identify any missing data.

Response: This has been added.

We will be happy to provide any additional clarifications or edits as necessary.

Yours sincerely,

Sian White

Corresponding Author

London School of Hygiene and Tropical Medicine

Decision Letter 1

Ginny Moore

31 Mar 2020

The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq

PONE-D-19-25323R1

Dear Dr. White,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

You will see that Reviewer #2 has made a couple of minor suggestions that you may wish to take into consideration if you are required to make any technical amendments to your manuscript. Please also clarify the result presented in lines 257-8 (that when citing positive consequences of handwashing there were no significant differences between groups) as Table 4 (camp 1) suggests otherwise (to get rid of dirtiness p=0.042*).  

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I found the paper to be very well written - especially the discussion and conclusion. Thank you for your hard work.

A few comments:

The objective is a bit unclear. Is it to understand the barriers for handwashing or to compare the Barrier Analysis with other tools? It seems to flip back and forth in the intro/methods.

Line 220: Why is n=156? Wouldn’t it be 180?

Line 272: Please explain: “non-doers were 18% more likely than doers to report a lack of 273 negative consequences (doers = 80%, non-doers= 98%, p=0.008)”

In the results, the descriptions seem to go from ‘doers and non-doers’ – to more then more general ‘people’ or C1 and C2 – obviously those are different groups, and reporting 18% of XXX can mean very different things depending on the specific description. Please be aware that can be difficult for the reader.

Line 447: There are 2 periods.

Reviewer #3: Authors have adequately addressed my comments and I would like to recommend this paper for publication

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Reviewer #2: No

Reviewer #3: No

Acceptance letter

Ginny Moore

30 Apr 2020

PONE-D-19-25323R1

The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq

Dear Dr. White:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ginny Moore

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Barrier analysis questionnaire.

    (DOCX)

    Data Availability Statement

    The Barrier Analysis Questionnaire used during this study is attached as a supplementary material. All data analysis files are available from the Figshare database (URL: https://doi.org/10.6084/m9.figshare.8152751.v1)


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