Hygiene promotion interventions are likely to be more effective if they target the determinants of handwashing behaviour. Synthesis of the evidence on the determinants of handwashing behaviour is needed to enable practitioners to use evidence in hygiene promotion programming. To identify, define and categorise the determinants of handwashing behaviour in domestic settings and to appraise the quality of this evidence. We conducted an integrative review, searching three databases for terms related to handwashing and behaviour change determinants. Studies were summarised and their quality assessed against a pre-defined set of criteria for qualitative, quantitative and mixed-method studies. Data on determinants were extracted and classified according to a predefined theoretical taxonomy. The effect of each association between a determinant and handwashing behaviour was summarised and weighted based on the quality of evidence provided. Determinants that were reported more than three times were combined into a meta-association and included in the main analysis. Sub-analyses were done for studies conducted during outbreaks or humanitarian crises. Seventy-eight studies met the criteria. Of these, 18% were graded as 'good quality' and 497 associations between determinants and handwashing behaviour were extracted. We found that 21% of these associations did not clearly define the determinant and 70% did not use a valid or reliable method for assessing determinants and/or behaviour. Fifty meta-associations were included in the main analysis. The determinants of handwashing that were most commonly reported were knowledge, risk, psychological trade-offs or discounts, characteristic traits (like gender, wealth and education), and infrastructure. There was insufficient data to draw conclusions about the determinants of behaviour in outbreaks or crises. This review demonstrates that our understanding of behavioural determinants remains sub-optimal. We found that there are limitations in the way behavioural determinants are conceptualised and measured and that research is biased towards exploring a narrow range of behavioural determinants. Hygiene promotion programmes are likely to be most successful if they use multi-modal approaches, combining infrastructural improvement with 'soft' hygiene promotion which addresses a range of determinants rather than just education about disease transmission.

Humanitarian crises such as disease outbreaks, conflict and displacement and natural disasters affect millions of people primarily in low- and middle-income countries. Here, they often reside in areas with poor environmental health conditions leading to an increased burden of infectious diseases such as gastrointestinal and respiratory infections. Water, sanitation, and hygiene behaviours are critical to prevent such infections and deaths. A scoping review was conducted to map out what is known about the association between three mental health disorders and people’s perceived and actual ability to practice hygiene-related behaviours, particularly handwashing, in humanitarian and pandemic crises. Published and grey literature was identified through database searches, humanitarian-relevant portals, and consultations with key stakeholders in the humanitarian sector. 25 publications were included, 21 were peer-reviewed published articles and four were grey literature publications. Most of the studies were conducted in mainland China (n = 12) and most were conducted in an outbreak setting (n = 20). Six studies found a positive correlation between handwashing and anxiety where participants with higher rates of anxiety were more likely to practice handwashing with soap. Four studies found an inverse relationship where those with higher rates of anxiety were less likely to wash their hands with soap. The review found mixed results for the association between handwashing and depression, with four of the seven studies reporting those with higher rates of depression were less likely to wash their hands, while the remaining studies found that higher depression scores resulted in more handwashing. Mixed results were also found between post-traumatic stress disorder (PTSD) and handwashing. Two studies found that lower scores of PTSD were associated with better hygiene practices, including handwashing with soap. The contradictory patterns suggest that researchers and practitioners need to explore this association further, in a wider range of crises, and need to standardize tools to do so.

Background: Internally displaced persons fleeing their homes due to conflict and drought are particularly at risk of morbidity and mortality from diarrhoeal diseases. Regular handwashing with soap (HWWS) could substantially reduce the risk of these infections, but the behaviour is challenging to practice while living in resource-poor, informal settlements. To mitigate these challenges, humanitarian aid organisations distribute hygiene kits, including soap and handwashing infrastructure. Our study aimed to assess the effect of modified hygiene kits on handwashing behaviours among internally displaced persons in Moyale, Ethiopia.Methods: The pilot study evaluated three interventions: providing liquid soap; scented soap bar; and the inclusion of a mirror in addition to the standard hygiene kit. The hygiene kits were distributed to four study arms. Three of the arms received one of the interventions in addition to the standard hygiene kit. Three to six weeks after distribution the change in behaviour and perceptions of the interventions were assessed through structured observations, surveys and focus group discussions.Results: HWWS was rare at critical times for all study arms. In the liquid soap arm, HWWS was observed for only 20% of critical times. This result was not indicated significantly different from the control arm which had a prevalence of 17% (p-value = 0.348). In the mirror and scented soap bar intervention arms, HWWS prevalence was 11 and 10%, respectively. This was indicated to be significantly different from the control arm. Participants in the focus group discussions indicated that liquid soap, scented soap bar and the mirror made handwashing more desirable. In contrast, participants did not consider the soap bar normally distributed in hygiene kits as nice to use.Conclusion: We found no evidence of an increased prevalence of handwashing with soap following distribution of the three modified hygiene kits. However, our study indicates the value in better understanding hygiene product preferences as this may contribute to increased acceptability and use among crisis-affected populations. The challenges of doing research in a conflict-affected region had considerable implications on this study’s design and implementation.Trial registration: The trial was registered atwww.ClinicalTrials.gov6 September 2019 (reg no:NCT04078633).

Wash’Em is a process that supports humanitarians in assessing and designing rapid but context-specific hygiene programmes in crises or outbreaks. The process consists of training implementers, using tools to learn from populations, and entering findings into a software which generates contextualised activities. A process evaluation of Wash’Em use was conducted in a drought-affected area in Midland province, Zimbabwe. Data were collected during the programme design and following implementation using a mix of qualitative methods. Findings were classified against the intended stages of Wash’Em, and the evaluation domains were defined by the UKRI Medical Research Council. The Wash’Em process was not fully implemented as intended. An abridged training was utilised, some of the tools for learning from populations were omitted, many of the recommended activities were not implemented, the delivery modalities were different from intended, the budget available was minimal, and the number of people exposed to activities were fewer than hoped. Despite these ‘on the ground’ challenges and adaptations, the Wash’Em process was considered feasible by implementers and was seen to be less top–down than most programme design approaches. The populations exposed to the intervention found the activities engaging, understood the content, and reportedly took action to improve handwashing behaviour. Programmes such as Wash’Em, which facilitate community participation and are underpinned by theory and evidence, are likely to yield positive results even if processes are followed imperfectly.

Objectives This multicountry analysis aimed to assess the prevalence of key hygiene prevention behaviours and their determinants, associated with international non-governmental organisation (WaterAid) hygiene behaviour change programmes for COVID-19 prevention. The goal of this analysis is to inform future outbreak preparedness and pandemic response in low and middle-income countries. Design Cross-sectional study. Setting Households in seven countries where WaterAid implemented a first-phase COVID-19 response programme in 2020 (Ethiopia, Ghana, Nepal, Nigeria, Rwanda, Tanzania and Zambia). Participants 3033 adults (1469 men and 1564 women, alternately sampled from one household to the next to maintain gender balance) in specific programme areas (211 villages) surveyed between October and November 2020. Primary outcome measures Self-reported primary outcomes were: a composite measure of HWWS for prevention of respiratory infection/COVID-19 (total of 5 key moments); respondent increased HWWS behaviour after the COVID-19 pandemic; respondent always wears a mask in public spaces; respondent always practices physical distancing in public spaces. Results Most respondents (80%) reported increasing their handwashing behaviour after the pandemic, but practice of HWWS at COVID-19-specific prevention moments was low. Mask wearing (58%) and physical distancing (29%) varied substantially between countries. Determinants of key behaviours were identified, including age and socioeconomic status, perceived norms, self-regulation and the motive of protecting others. Incidence rate ratios or odds ratios and 95% CIs for a range of psychosocial determinants for each of the four primary outcomes are reported. Conclusions These findings highlight that leveraging behaviour-specific emotional drivers and norms, reducing common barriers and promoting targeted messages about specific behaviours and actions individuals can take to reduce risk are necessary to support large-scale behaviour change. Learning from the COVID-19 response to more effectively integrate novel behaviours into existing health promotion will be vital for disease prevention and outbreak resilience.

Background Internally displaced persons (IDPs) forced to flee from their homes due to conflict and drought are at particular risk of morbidity and mortality due to diarrhoeal diseases. Regular handwashing with soap could substantially reduce the risk of these infections, but the behaviour is challenging to practice while living in resource-poor, informal settlements. To mitigate these challenges, humanitarian aid organisations distribute hygiene kits including soap and handwashing infrastructure. Our study aimed to assess the effect of modified hygiene kits on handwashing behaviours among IDPs in Moyale, Ethiopia. Methods The pilot study evaluated three interventions separately; liquid soap, a ‘good quality’ scented bar soap and a mirror as modifications to a standard hygiene kit. The hygiene kit was distributed to four study arms, with three of the arms receiving one of the interventions in addition. Three to six weeks after distribution, behaviour change and perceptions of the interventions was assessed through structured observations, surveys and focus group discussions. Results At follow-up, handwashing with soap was rare at key times in all study arms. In the arm that received liquid soap, handwashing with soap was seen at 20% of key times but this was not indicated significantly different to the control arm were a prevalence of 17% (p-value=0.348). In the two other intervention arms prevalence was <11%. Participants in FGDs indicated that the liquid soap, scented bar soap and the mirror made handwashing more desirable. In contrast the standard bar soap distributed in hygiene kits was not viewed as being nice to use. Conclusion This study did not identify any effect of the modified kits on handwashing behaviour. However, it did indicate that there is value in better understanding hygiene product preferences as this may contribute to increased acceptability and use among crisis-affected populations. The challenges of doing research in conflict-affected regions had considerable implications on the design and implementation of this study.Trial registration The trial was registered at www.ClinicalTrials.gov 6 September 2019 (reg no: NCT04078633)