how is hygiene behaviour affected by conflict and displacement a qualitative case CORD-Papers-2022-06-02 (Version 1)

Title: How is hygiene behaviour affected by conflict and displacement? A qualitative case study in Northern Iraq
Abstract: This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different post-conflict settings in Northern Iraqa long-term displacement camp a short-term displacement camp and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and of these 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical psychological social and economic circumstances of displaced populations. Future hygiene programmes in post-conflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency build on adaptive norms create an enabling environment and which are integrated with other aspects of humanitarian response.
Published: 2022-03-03
Journal: PLoS One
DOI: 10.1371/journal.pone.0264434
DOI_URL: http://doi.org/10.1371/journal.pone.0264434
Author Name: White Sian
Author link: https://covid19-data.nist.gov/pid/rest/local/author/white_sian
Author Name: Heath Thomas
Author link: https://covid19-data.nist.gov/pid/rest/local/author/heath_thomas
Author Name: Khalid Ibrahim Waleed
Author link: https://covid19-data.nist.gov/pid/rest/local/author/khalid_ibrahim_waleed
Author Name: Ihsan Dilveen
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ihsan_dilveen
Author Name: Blanchet Karl
Author link: https://covid19-data.nist.gov/pid/rest/local/author/blanchet_karl
Author Name: Curtis Val
Author link: https://covid19-data.nist.gov/pid/rest/local/author/curtis_val
Author Name: Dreibelbis Robert
Author link: https://covid19-data.nist.gov/pid/rest/local/author/dreibelbis_robert
sha: 056360b756543fbd84dbf9ff97f9618238f2be94
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: PMC
source_x_url: https://www.ncbi.nlm.nih.gov/pubmed/
pubmed_id: 35239702
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/35239702
pmcid: PMC8893612
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8893612
url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8893612/
has_full_text: TRUE
Keywords Extracted from Text Content: Nargizlyia people Ninewa Governorate Survey-based human Sinjar water Sheikhan people's her persons walls authors-DI IDP handwashing-such skin human."-Woman human bodies [3] water AHH Sheikhan research-58 that."-Man piped water WASH Sheikhan Camp facilities line wall [8] [9] [10] [11] . NGOs plastic."-Man AAH [2] Arabic Nargizlia doing"-Woman toilet Nurture � Conflicts man children lathered WKI People Hawler Medical University. everything."-Woman London School of Hygiene Sheikhan Camp Nargizlia Camp, 49 in women spaces her neighbour participants Nargizlia Camp residents [7] sections rice [12] friends people BCD soap."-Man turn."-Man IDPs TH Taps Wash'Em Honar Tara people Sian Waleed Karine Le Roch Basima
Extracted Text Content in Record: First 5000 Characters:This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different postconflict settings in Northern Iraq-a long-term displacement camp, a short-term displacement camp, and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and, of these, 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical, psychological, social and economic circumstances of displaced populations. Future hygiene programmes in postconflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency, build on adaptive norms, create an enabling environment and which are integrated with other aspects of humanitarian response. Data Availability Statement: Some relevant data are within the Supporting Information files. The transcripts of the interviews and group discussions are publicly available in redacted form via an open repository which can be accessed via the following studies on hygiene behavioural determinants remained poor and that studies disproportionally reported on personal characteristics and cognitive determinants [12] . Determinants such as routines, norms, contextual factors, motives, and the physical and biological environments were less frequently described in the literature. Although the review conducted a sub-analysis about the determinants of handwashing behaviour during humanitarian crises, no conclusions could be drawn due to the limited number of studies in these settings. Other reviews have also highlighted the lack of hygiene behaviour change research specific to crisis-affected settings, the poor quality of this research and the challenges of doing handwashing behaviour change in these settings [4, 13, 14] . However, broader literature indicates that major life events, and changes to physical and social circumstances, are likely to interrupt prior habits, create new norms, and introduce new enablers or barriers to behaviour [15, 16] , meaning that behavioural changes are likely to occur during crises even if poorly understood to date. Understanding the determinants of handwashing behaviour during crises has therefore been identified as a sector priority [17, 18] , particularly as humanitarians are under increasing pressure to develop guidelines and programmes that are based on evidence-based [19, 20] . Most studies on handwashing behaviour in crisis-affected settings have used survey-based methods to understand determinants and self-reported behaviour [21] [22] [23] [24] [25] . Survey-based approaches can only explore determinants that they identify in advance and these typically focus on knowledge, risk perception, personal characteristics, and capability. Self-reported handwashing behaviour measures are also known to over-estimate actual practice [26, 27] . Given that the determinants of hygiene are a poorly understood phenomenon, rooted in human experience, and often driven by sub-conscious factors, qualitative methods may be better placed to facilitate meaning making on this topic. This research aims to qualitatively explore whether the determinants of handwashing behaviour change according to the type of setting that people are displaced to, and the stage of their displacement. Methods This study took place in three study sites in Northern Iraq between June and August 2017 during the peak of the offensive against the Islamic State of Iraq and the Levant (hereafter referred to as Da'ish). We selected research sites purposively to reflect different durations of displacement (e.g. a short-term displacement camp, a long-term displacement camp and returnee villages), different social and physical settings within a conflict (e.g. comparing 'closed' verses 'open' camp settings, and comparing tented shelters to damaged buildings), and differences in water, sanitation, and hygiene (WASH) coverage. The first site was the tented Nargizliya Camp located within Dohuk Governorate in the Kurdistan Region of Iraq. Founded 6 months prior to data collection, Nargizliya housed 9,905 people who were predominantly Arab and had fled from the city of Mosul and its surrounding villages. As a 'closed camp', residents in Nargizlyia were not allowed to leave without permission, and access to communications (e.g. mobile phones) was not permitted. The second site was Sheikhan Camp, another tented camp in Dohuk Governorate. Sheikhan Camp held a population of 5,371 Yazidi (Êzidî) people who had fled from the city of Sinjar and its surrounding villages in summer 2014 and who had resided in the camp for three years. Residents in Sheikhan were able to come and go from the camp freely and many work
Keywords Extracted from PMC Text: friends Sheikhan Camp 's people [21–25] toilet man IDPs skin Sheikhan Camp facilities participants human Survey-based bodies [15,16] Arabic People Nargizlyia lathered BCD people's Taps London School of Hygiene [8–11 AAH's Shabak Nargizlia WASH facilities– children Sheikhan Ninewa Governorate WASH [12] spaces piped water TH AHH Nurture WKI [7] Sinjar [17,18] NGOs IDP Hawler Medical University. [2] [29,65] [3] [19,20] Conflicts AAH water
Extracted PMC Text Content in Record: First 5000 Characters:Conflicts often create the 'perfect storm' of circumstances to enable communicable disease transmission [1]. This is because in the wake of conflict infrastructure and water and sanitation systems are often damaged, populations are displaced to densely populated areas, markets collapse, and health facilities are weakened or overburdened [2]. Consequently diarrhoeal and respiratory infections are the leading cause of preventable illness and death during crises [3]. Handwashing with soap has the potential to reduce the burden of diarrhoeal diseases, respiratory diseases and other outbreak-related pathogens [4–6]. However, handwashing rates are low globally [7] and likely to be even lower in post-conflict displacement contexts. Behaviour change theorists suggest that for behaviour change programmes to be effective, they must address the determinants that influence the behavioural outcome [8–11]. A recent systematic review of the determinants of handwashing behaviour found that the quality of studies on hygiene behavioural determinants remained poor and that studies disproportionally reported on personal characteristics and cognitive determinants [12]. Determinants such as routines, norms, contextual factors, motives, and the physical and biological environments were less frequently described in the literature. Although the review conducted a sub-analysis about the determinants of handwashing behaviour during humanitarian crises, no conclusions could be drawn due to the limited number of studies in these settings. Other reviews have also highlighted the lack of hygiene behaviour change research specific to crisis-affected settings, the poor quality of this research and the challenges of doing handwashing behaviour change in these settings [4,13,14]. However, broader literature indicates that major life events, and changes to physical and social circumstances, are likely to interrupt prior habits, create new norms, and introduce new enablers or barriers to behaviour [15,16], meaning that behavioural changes are likely to occur during crises even if poorly understood to date. Understanding the determinants of handwashing behaviour during crises has therefore been identified as a sector priority [17,18], particularly as humanitarians are under increasing pressure to develop guidelines and programmes that are based on evidence-based [19,20]. Most studies on handwashing behaviour in crisis-affected settings have used survey-based methods to understand determinants and self-reported behaviour [21–25]. Survey-based approaches can only explore determinants that they identify in advance and these typically focus on knowledge, risk perception, personal characteristics, and capability. Self-reported handwashing behaviour measures are also known to over-estimate actual practice [26,27]. Given that the determinants of hygiene are a poorly understood phenomenon, rooted in human experience, and often driven by sub-conscious factors, qualitative methods may be better placed to facilitate meaning making on this topic. This research aims to qualitatively explore whether the determinants of handwashing behaviour change according to the type of setting that people are displaced to, and the stage of their displacement. This study took place in three study sites in Northern Iraq between June and August 2017 during the peak of the offensive against the Islamic State of Iraq and the Levant (hereafter referred to as Da'ish). We selected research sites purposively to reflect different durations of displacement (e.g. a short-term displacement camp, a long-term displacement camp and returnee villages), different social and physical settings within a conflict (e.g. comparing 'closed' verses 'open' camp settings, and comparing tented shelters to damaged buildings), and differences in water, sanitation, and hygiene (WASH) coverage. The first site was the tented Nargizliya Camp located within Dohuk Governorate in the Kurdistan Region of Iraq. Founded 6 months prior to data collection, Nargizliya housed 9,905 people who were predominantly Arab and had fled from the city of Mosul and its surrounding villages. As a 'closed camp', residents in Nargizlyia were not allowed to leave without permission, and access to communications (e.g. mobile phones) was not permitted. The second site was Sheikhan Camp, another tented camp in Dohuk Governorate. Sheikhan Camp held a population of 5,371 Yazidi (Êzidî) people who had fled from the city of Sinjar and its surrounding villages in summer 2014 and who had resided in the camp for three years. Residents in Sheikhan were able to come and go from the camp freely and many worked in the nearby town. The third site included two neighbouring villages on the outskirts of Mosul in the Ninewa Governorate of Iraq. Residents of these villages had been displaced during the conflict and had returned within the last few months to homes damaged during the conflict. At the time of the research, 134 Arab or Shabak families h
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