Barriers and motivators to participation in hand washing promotion programs at household level among refugees in Rhino Settlement, Arua District _ Uganda

Abstract Introduction: The major aim of hand washing promotion programs is to persuade people to change their behaviour to reduce high-risk hygiene practices and use. Unfortunately, in a refugee setting, there is a dearth of information about participation in hand washing promotion programs. Objective: To assess barriers and motivators to participation in hand washing promotion programs at household level among refugees in Rhino Camp, Arua district, Uganda. Methods: A cross-sectional study was conducted to collect quantitative and qualitative data. A semi-structured questionnaire was used to collect data on participation, individual, household factors related to hand washing promotional programs from 312 refugees. Five key informant interviews were conducted to gather data on public policy, institutional and community factors related to participation in the hand washing promotion programs. Qualitative data were analyzed using thematic content analysis. Results: Only 19.6% (61/312) of the refugees had participated in hand washing promotion programs. Significant barriers to participation were; no formal education and staying in the camp for more than 3 years. The significant motivators were; households who had 6 to 10 members and more. Conclusion: Participation in hand washing promotion programs was low among the refugees. There is need for relevant stakeholders to come up with interventions to increase participation among the refugees while taking into consideration the potential barriers and motivators to their participation as identified by this study.


Background
According to the United Nations High Commissioner for Refugees ([UNHCR], 2018), nearly 20 people are being forcibly displaced every minute as a result of conflict or persecution worldwide. The most current UNHCR statistics show that there are nearly 22.5 million refugees globally; with Africa being the largest host continent for these refugees (UNHCR, 2018). This high influx of refugees consequently results in overcrowded conditions and limited water, hygiene and sanitation (WASH) facilities making them highly susceptible to communicable disease outbreaks (Hershey et al., 2011). The most frequent form of these diseases is those transmitted through the fecal-oral route such as diarrhoea and viral hepatitis A and E (UNHCR, 2018). Consequently, research findings have shown that diarrhoea causes up to 49% of child mortality in refugee settings (Nannyonga, 2012;Teshale, 2010).
Given these conditions, hand hygiene is of substantial concern to populations affected by humanitarian emergencies in order to prevent the consequences of disease outbreaks. Research findings have consistently indicated the potential to reduce the risk of diarrhoea by up to 50% among young children by promoting hand washing with soap (Fewtrell et al., 2005). However, only 19% of people on average are estimated to wash their hands with soap following contact with excreta worldwide (Freeman et al., 2014). Therefore, there is a need to scale up hand washing promotion campaigns. The overall aim of hand washing promotion campaigns is to persuade people to change their behaviour to reduce high-risk hygiene practices and to use and maintain the appropriate facilities (Humanitarian Innovation Fund [HIF], 2013). Common approaches to hand washing promotion employed in refugee settings can be broadly classified as the social and physical approaches (HIF, 2016).
The social approaches are meant to empower the refugees with knowledge about hygiene and sanitation. According to research done in 2009 by the Water Supply and Sanitation Collaborative Council (WSSCC) social approaches seek to help refugees improve hygiene behaviours, reduce diarrheal diseases and encourage effective management of water and sanitation services. The different learning methodologies include; Participatory Hygiene and Sanitation Transformation (PHAST), childto-child approaches, child-to-community approaches, and community health clubs (Peal, 2010). Another important socially related initiative is the Global Hand Washing Day which is celebrated every 15 October th . This day was launched in 2008 by The Global Public Private Partnership for Hand Washing. The day aims to raise awareness of the importance of hand washing and critical moments to wash hands and has been celebrated in many refugee camps (HIF, 2016).
The physical approaches are meant to provide the refugees with the necessary materials to enable them to wash their hands such as soap and safe water containers. Different hand washing technologies have been employed in humanitarian settings and include; Oxfam buckets, tippy taps, bush proof hand washing containers, hand washing bags and communal wash stations (HIF, 2016). The success of such hand washing promotion interventions is highly dependent on the active participation of the refugees (Oxfam, 2010). There is need for active involvement of all sections of the refugee community in planning and decision-making processes related to the hand washing promotion program (Vujcic et al., 2014). The overall aim for this participation is to encourage people to take responsibility for the process and outcomes both in the short and long term in order to achieve sustainable hand washing behavioural practices (HIF, 2016). Therefore, vigorous assessment to identify potential barriers and motivators to participation in hand washing promotion programs in order to ensure sustainability is needed.
Studies related to motivators and barriers to participation in hand washing promotion programs have primarily been performed in stable developing country contexts (Curtis et al., 2009). However, in a setting of internal displacement or among the refugees; habits, social systems and cultural norms can be disrupted, thereby potentially altering participation and engagement mechanisms of the refugees. Therefore, to generalize research findings from a stable developing country context to be the same as those of a refugee setting would be inappropriate. There is a dearth of information about participation in hand washing promotion programs in refugee settings (Vujcic et al., 2014).

Secondary objectives of the study
To address the information gap by assessing the barriers and motivators to participation in hand washing promotion programs at household level among refugees in Rhino Camp, Arua district, Uganda.

Primary objectives of the study
The study had the following primary objectives; (1) To determine the level of participation in hand washing promotional programs at household level among refugees in Rhino Camp, Arua district, Uganda by July 2019.
(2) To establish the possession of hand washing facilities at the household level among refugees in Rhino Camp, Arua district, Uganda by July 2019.
(3) To describe the barriers and motivators to Participation in Hand washing promotion programs at household level among refugees in Rhino Camp, Arua district, Uganda by July 2019.
(4) To analyse the barriers and motivators to participation in hand washing promotion at household level among refugees in Rhino Camp, Arua district, Uganda by July 2019.

Study design
This was an analytical cross-sectional study, mixed method, whereby both quantitative and qualitative were employed. The study population for this study was adults aged 18 years and above residing in Rhino Camp settlement. The study participants were men and women in selected households who are currently living in Rhino Camp settlement.

Sample size
A sample size of 312 respondents was selected using the Kish Leslie formula (1965) for crosssectional studies as follows. Where; e = precision of the study. The precision of 5% was used for this study Z = standard normal deviate corresponding to the 95% confidence interval (CI), CI = 1.96 P = proportion of households in a refugee setting who had ever participated in hand washing promotion programs. P = 85% = 0.85.  Q = proportion of households in a refugee setting who did not participate in hand washing promotion programs. Therefore, Q = 1-P = 1-0.85 = 0.15 Considering a design effect of 1.6; the sample size shall be 196 × 1.6 = 312 Therefore, the sample size was 312 respondents.

Sampling method
This study employed the multi-stage sampling as follows: Rhino Camp is broadly divided into seven administrative zones. This study was carried out in all seven zones so as to get a general representation of the whole camp. However, two villages per zone were selected by simple random sampling. There are 123,363 refugees in the camp, residing in households of 4-6 persons.
Sampling of participating villages was done by entering all the names of the villages for each zone into a random function Excel spreadsheet and then using the random function, two villages per zone were selected. The selection of households from the chosen village to participate in this study was done by systematic random sampling. A compass was used to identify the starting direction and a predetermined interval of households was used. The village local leader provided the village population and directions within the villages. A sampling interval K was calculated by dividing the total number of households per village by the number of households targeted for inclusion in the study.
With guidance from the local leader, the research team located the centre of the selected village and then used a compass to identify the Northern direction as the starting direction for household interviews. Every K th household from the centre of the village in the Northern direction was considered until the village boundary was reached and the same pattern was repeated in different directions clockwise. The research assistants then interviewed only one participant per sampled household. In cases where there was more than one eligible participant, simple random sampling was used to select a respondent to answer the questionnaire. This was done by randomly picking from a bag a folded ballot paper with a number corresponding to the participant's name who was interviewed.
For the key informant interviews, four hygiene promoters and 1 WASH officer were purposively selected. They were interviewed to obtain information on the institutional, public policy and community factors affecting participation in hand washing promotion programs.

Data collection tools and methods
The study employed both quantitative and qualitative approaches of data collection as follows:

Quantitative data collection methods and instruments
The quantitative data for this study were collected through household interviews using a standardized semi-structured questionnaire. The questionnaire was composed of both openand closed-ended questions. It helped to capture data on knowledge about hand washing and its importance, attitudes towards hand washing, cultural beliefs about hand washing and sociodemographic characteristics, among others. Responses were self-declared by responding to a single question at a time.

Qualitative data collection
The qualitative data for this study were collected through key informant interviews using a key informant interview guide. The interview guide captured data on institutional factors like availability of IEC materials, availability of hand washing facilities and availability of hygiene promoters, Public Policy factors such as Sphere standards, Uganda Refugee Act 2006 and Cholera Prevention and Control guidelines and Community factors like availability of Community groups and Involvement of community leaders in decision making.

Quality control
Pre-visits to the study site were made to build rapport with the community leaders at Rhino Camp and research assistants with good knowledge of the local languages were identified and trained. Two days training was done to ensure good understanding of the goals and aims of the study.
Questionnaires were designed with expert opinion to ensure they showed a logical flow of questions and were able to collect the needed data. There were translation and back translation of the questionnaires, which were pre-tested in an area that was not be used in data collection.
The supervisor conducted spot checks on all data collected using questionnaires to ensure data accuracy. Debrief meetings were held with data collectors at the end of each day to review questionnaires and record any incidents/events occurring during data collection. There was regular supervision by the Principle Investigator.
For qualitative data, key informant interviews were tape-recorded and field notes were also taken.

Ethical consideration
All ethical considerations for research were adhered to. This included ethical clearance and approval by relevant authorities, informed consent and confidentiality, among others. Uganda Martyrs' University, Faculty of Health Sciences, gave ethical clearance and approval for this study.

Quantitative data
Quantitative data were double entered in Epidata version 3.1. The discrepancies within the two data sets were corrected during data cleaning. It was then exported into Stata version 13.0 for data analysis.
Descriptive analysis was carried out with the aim of answering objectives one and two (To determine the level of uptake of household visits aimed at promoting hand washing and to determine the level of use of hand washing facilities). This information was summarized in percentages.
Since the main outcome of interest (participation in hand washing promotional programs) was binary (yes/no), further analysis required logistic regression as the appropriate mode of analysis.
Univariate analysis was done using logistic regression to establish associations between each independent variable and the outcome (participation). An analysis of the relationship between participation in hand washing promotional programs and different independent variables like age, length of stay in the camp and knowledge towards hand washing was carried out. Crude odds ratios with corresponding 95% confidence intervals were computed and variables with probability (P) values less than or equal to 0.05 were considered to be significantly associated with participation in hand washing promotional programs.
Multivariate analysis was also carried out to control for the other variables (confounding). This was determined by observing differences in the relationship between the independent variables and whether a respondent participates or does not participate in hand washing promotion programs.
Variables with P values less than or equal to 0.2 were included in the multivariate analysis, variables that met this criterion as well as those deemed important in determining participation in hand washing promotion programs from prior literature were also considered. The stepwise method of elimination of variables was used to create the model.

Qualitative data
All the key informant interviews were transcribed verbatim. They were analysed using a software for qualitative analysis; ATLAS.ti.8.0. Two research assistants read the transcripts several times and independently developed code books. The members then discussed any arising issues and agreed on a final codebook. Thematic content analysis was the form of analysis used. This was done by coding responses from the transcripts and then categorised into emerging themes and subthemes. Code counts were done to determine the strength of responses.

Socio-demographic characteristics of the respondents
A total of 312 respondents were recruited for the study and all of them participated representing 100% response rate. The majority of respondents; 70.8% (221/312) were female, 67.9% (212/312) were married. The mean age of respondents sampled was 32.7 years. Majority of the respondents; 52.9% (165/312) had ever attended school and 74.0% (231/312) had lived in the camp for less than or equal to 3 years.

Level of participation in hand washing promotional programs at household level
The study findings revealed that only 19.6% (61/312) of the refugees had participated in the hand washing promotion programs within the settlement. 80.4% of the respondents never participated in the programs.

Possession of hand washing facilities at the household level
A minority of the participants; 39.4% (123/312) had a hand washing Facilities/station (HWS) at their households, with tippy taps; 84.6% (104/123) being the most common form of HWSs. On average each HWS served eight people with most of the HWSs having water; 89.4% (110/123) and soap; 60.2% (74/123) present. The lack of materials; 44.3% (66/149) to set up the HWS was the most frequent reason for households who lacked a HWS (Table 1).

Findings from key informants
All the key informants described the hand washing promotion programs at the household level entailed both a social component (sensitization) and a physical component (provision of tippy taps and ropes). For example: […] we have the tippy-tap approach where every household that has a latrine is given a tippy-tap jerry can of either three litres or five litres plus the rope for installing it. This is always done before sensitization exercise. When we are going for distribution, we first do sensitization which is coupled with demonstration on how to install the tippy-taps. (Key Informant III)

Descriptive findings on barriers and motivators to participation in hand washing promotion programs
This sub-section presents descriptive results of the various potential barriers and motivators to participation in hand washing promotion programs. The barriers and motivators presented in this sub-section include; knowledge and attitudes towards hand washing and availability and accessibility of essential materials (soap and water) needed for hand washing.

Knowledge about hand washing
Majority of the respondents; 90.4% (282/312) mentioned after visiting the toilet as the critical time for hand washing with avoiding diseases; 74.0% (231/312) as the most mentioned primary purpose for hand hygiene. The majority of the respondents; 95.5% (298/312) acknowledged the importance of using soap during hand washing (Table 2).

Attitudes about hand washing
Majority of the respondents; 43.3% (135/312) and 41.7% (130/312) strongly agreed that there was a need to wash hands before feeding and hand washing was important for child development, respectively. Overall, there was a generally positive attitude towards hand washing among most participants (Table 3).
However, despite the majority of positive attitudes exhibited by the study respondents, one of the key informants noted some behaviours which are not consistent with the good attitude, as can be observed in the quote below: […] I think the communities are not practicing well, they are not putting it into practice to our expectations like we go back to do our assessment, we find tippy-taps we gave to them are not installed, they don't even put water into the jerry can meaning they do not use the facilities how they should […].

(Key Informant I)
Nonetheless, one key informant noted some good behaviour, which is attributable to positive attitude. He revealed that exemplary neighbours who actively participated in these promotional programs were a major motivator for the non-participating neighbours to also take part in these programs. This can be seen in the quote below: Other 1 included; inside latrine and within the compound.
Other 2 included; reluctant to put the HWS and HWS still under construction.
[…] if the neighbour did the correct hand washing, it motivates other households to do likewise … (Key Informant II).
Key informants suggested the need for engagement of community leaders who guide the community to come up with rules which act to reinforce positive practices in the reluctant communities who are not willing to participate in these programs. For example: […] My recommendation would be to maximize engagement of the leaders, the refugee leaders for instance, such that they can be in position to put rules that will govern the use of hand washing at household level in such a way that if someone does not have the facilities a condition must be put in place for such a person to meet a certain deadline[…] (Key Informant III) Further, they also suggested the need for frequent follow up for the households to mitigate the barrier of community reluctance to participate in the hand washing promotion programs, as can be seen in the quote below: […] being as close as possible to these people, like partners. They need you to be behind them so much that every time they don't forget. If you come for an activity like WASH once in a month, the reluctance among the households will arise and so partners should be very close to them to make follow-ups (Key Informant I) They also suggested that rewarding active participants of the hand washing promotion programs would be a way of motivating many of households to participate in such programs: Appreciating outstanding active households with simple rewards like saucepans would be a good way of motivating other households to actively participate in these programs (Key Informant IV)

Availability and accessibility factors related to soap and water
A public tap; 65.7% (205/312) was the most common main water sources with most of the water sources, 85.9% (268/312) being within a distance of 500 m. Majority of the households, 97.1% (265/312) obtained their soap from a retail shop. However, only 2.6% (7/312) reserved soap for hand washing as a high priority (Table 4).

Bivariate analysis of motivators and barriers to participation in hand washing promotion programs
With reference to Table 6, participants who had never attended school were 33% less likely to participate in hand washing promotion programs than those who had attended school (CI = 0.17-0.61; P-value = 0.00). In addition, those who had stayed in the camp for more than 3 years were also 40% less likely to participate in the promotional programs than their counterparts (CI = 0.17-0.81; P-value = 0.01) Households who had 6 to 10 members and those with more than 10 members had 2.67 (CI = 1.27-5.62; P-value = 0.01) and 2.63 (CI = 1.03-6.73; P-value = 0.04) times the odds of engaging in promotional programs than those households with 1 to 5 members, respectively (See Table 5).

Multivariate analysis of motivators and barriers to participation in hand washing promotion programs
With reference to Table 6, participants who had never attended school were 30% less likely to participate in hand washing promotion programs than those who had attended school (CI = 0.15-0.60; P-value = 0.001). In addition, those who had stayed in the camp for more than 3 years were also 40% less likely to participate in the promotional programs than their counterparts (CI = 0.17-0.93; P-value = 0.03).
Households who had 6 to 10 members and those with more than 10 members were more 3.06 (CI = 1.35-6.93; P-value = 0.01) and 2.92 (CI = 1.04-8.17; P-value = 0.04) times more likely to engage in promotional programs than those households with 1 to 5 members, respectively (See Table 6).

Participation in hand washing promotion activities
The study findings revealed low participation in hand washing promotion activities, as only 19.6% (61/ 312) of the study respondents had participated in the hand washing promotion programs within the settlement. This can probably be attributed to the fact that majority, 65.7% were receiving less than 10 l of water daily for their entire household needs. This might have probably led to their lack of participation, since limited access (less than 10 l daily per household) to water hinders effective participation in hand washing promotion (Spiegel et al., 2010). This finding is in agreement with the study by Ayiga and Nick (2015) in the nearby Nyumanzi Refugee Settlement Camp in Adjumani District, Uganda, which also reported poor levels of participation of refugees in hand washing  (Husain et al., 2015), where the level of participation in hand washing promotion was high among the refugees.
The differences in findings between these studies (in Uganda and in Ethiopia) could be attributed to differences in study settings, with the Ethiopian setting being more urbanized than the current study setting. However, it can also be attributed to the fact that the study in Ethiopia (Husain et al., 2015) was conducted among internally displaced persons whereas in the current study all the refugees were foreign. Possibly their native nationality in the Ethiopian case enabled them to have better opportunities of accessing adequate water supply, which could have improved their chances of participation in hand washing promotion activities, which was not the case in the current study.
Hence, it is important for government, NGOs, and other stakeholders in the WASH area, to put in more effort to promote hand washing activities in Rhino Camp and other low resource settings so as to improve the participation of refugees in those areas in order to reduce the chances of outbreaks of diarrhea and other diseases.

Use of hand washing facilities
The finding revealed that a high percentage of household members used hand washing facilities, which could possibly be attributed to the existence of several NGOs which are promoting hand washing activities in the area. The findings are in agreement with the study by Biran et al. (2011) in Thailand, Ethiopia and Kenya which also reported good access to hand washing stations.

Barriers and motivators to participation in hand washing promotion
According to the results from multivariate analysis, the barriers to participation in hand washing promotion included: having never attended school, and having stayed in the camp for more than 3 years. Possibly having not acquired formal education made it hard for them to appreciate the need for participating in hand washing promotion activities, as was also reported in the study by Grayson et al. (2009). Further, having stayed in the camp for long (more than 3 years), could have made them to become complacent when it comes to participating in hand washing promotion. This finding is supported by Marie-Rosette et al. (2017) who also reported that staying in camps for long has a negative relationship with participating in hand washing promotion. However, it disagrees with Scobie et al. (2017) who reported that people who spend longer time in refugee camps are expected to be exposed to hand washing promotion activities and would have adopted good hygiene practices (Scobie et al., 2017). But this is not always the case in refugee camps. Hence, these findings illustrate the need for hand washing promoters to lay more emphasis on supporting people who stay in refugee camps for long times, to continue embracing good hand washing promotion activities.
According to the results from multivariate analysis, the promoters for participation in hand washing promotion included: having some formal education level, and having six or more household members. Education causes empowerment of persons, thereby making them have better perceptions regarding issues of health nature (Grayson et al., 2009). Similarly, having big family or household size (six or more) could have enabled them to participate in hand washing promotion activities because lack of participation is likely to have greater negative consequences to big families than small ones. This finding, however, is disputed by Madhur and Rana (2016) who reported no association between family size and hand washing practices. The differences in findings could be attributable to differences in study settings.

Conclusion
Despite the high presence of hand washing facilities, participation in hand washing promotional activities is low among the refugees in Rhino Camp, and this is attributable to having never attended school, and having stayed in the camp for more than 3 years. Among the few who participate, the participation in hand washing promotional activities is mainly attributable to having some formal education, and having big family size of six or more members.