Sociodemographic characteristics of households who participated in structured observation and survey
In total, 400 households received a hygiene kit. Of these, 203 households were enrolled for structured observation. Despite the study regions being selected for their similarity, we found variation within population demographics. The control arm was a mixture of people of the Borena and Gabbra ethnic groups, while the populations in the intervention arms consisted entirely of people from the Borena ethnic group. IA3-Mirror was located 13 km from the main road in an area more affected by drought and flooding, while the other study arms were located along or within 1km of the main road. Of the randomly selected households, six households in IA3-Mirror were not available for data collection as floods hindered data collectors from reaching the household. Four households in IA1-Liquid and six households in IA2-Scented were not available on follow-up because the ongoing economic hardships, drought and conflict had caused them to move on. These variations between study arms were unfortunately unable to be identified prior to the study due security limitations in accessing the sites.
Animal ownership was over 90% in the three intervention arms but only 54% in the control arm. In the control arm results also showed slightly lower rates of educational attainment and household income and people in this study arm had to spend more time queuing to access water compared to the intervention arms. The majority of participants in all study arms had received no formal education. The mean number of people per household was similar across all study arms. All households in IA1-Liquid and the control arm were Muslims, while in IA2-Scented and IA3-Mirror participants were Protestants, Muslims or practiced Wakefata (a local religion). The majority of respondents were displaced due to conflict, but eight percent and thirty percent of respondents in IA2-Scented and IA3-Mirror respectively were displaced due to drought (Table 1).
Table 1. Sociodemographic data and household characteristics of the in a 4-armed exploratory pilot study in Moyale, Ethiopia.
Variable
|
Control arm
n=50
|
Intervention Arm 1: Liquid
n=50
|
Intervention Arm 2: Scented
n=51
|
Intervention Arm 3: Mirror n=52
|
Number of people per household, mean (SD)
|
6.94 (2.65)
|
6.52 (2.56)
|
7.22 (2.15)
|
6.60 (2.62)
|
Number of children <5 per household, mean (SD)
|
1.4 (1.01)
|
1.72 (0.86)
|
1.86 (1.51)
|
1.15 (0.89)
|
Respondents education, % (n)
No education
Primary school completed
Secondary school completed
Higher education completed
|
|
|
|
|
80% (39)
|
62% (31)
|
63% (31)*
|
73% (38)
|
16% (8)
|
26% (13)
|
24% (12)*
|
21% (11)
|
4% (2)
|
10% (5)
|
10%(5)*
|
6% (3)
|
0% (0)
|
2% (1)
|
2% (1)*
|
0% (0)
|
Household Income per week (ETB), mean (SD)
|
189.29 (212.85)
|
219.79 (223.98)*
|
269.36 (272.53)*
|
222.06 (286.11)
|
Animal ownership (owning at least one domestic animal cow, camel, donkey, goat, sheep or chicken), % (n)
|
54% (27)
|
92% (46)
|
98% (50)
|
98% (51)
|
Religion, % (n)
Muslim
Wakefata (local religion)
Protestant
No religion
|
|
|
|
|
100% (50)
|
100% (50)
|
61% (31)
|
46% (24)
|
0% (0)
|
0% (0)
|
33% (17)
|
38% (20)
|
0% (0)
|
0% (0)
|
4% (2)
|
15% (8)
|
0% (0)
|
0% (0)
|
2% (1)
|
0% (0)
|
Reason for displacement, % (n)
Conflict
Drought
Other**
|
|
|
|
|
100% (50)
|
98% (49)
|
74% (37)*
|
56% (28)
|
0% (0)
|
0% (0)
|
8% (4)*
|
30% (15)
|
0% (0)
|
2% (1)
|
18% (9)*
|
14% (7)
|
Water collection duration (round trip) in minutes, mean (SD)
|
103 (77.15)
|
74 (60.19)
|
56 (65.54)
|
102 (71.29)
|
Water available per person in the household in litres, mean (SD)
|
14 (5.8)
|
13 (6.04)
|
12 (5.09)
|
14 (5.01)
|
* Percentages were estimated from slightly smaller denominators than those shown at the top of the table for the following variables due to unanswered survey questions/missing values.
** Other reasons for displacement included moving for job opportunities or family reasons.
Availability of handwashing facilities, soap and water
Table 2 presents the results from the household survey. Out of the 400 households that received the hygiene kits 16 households did not have the handwashing facilities available during the follow up visit. Among the households which had the handwashing facility present during the follow up visit, 88% of facilities had water in them. Soap presence at the handwashing facility (any type of soap) was highest in control arm (66%) while in IA1-Liquid, IA2-Scented and IA3-Mirror soap was present in 44%, 27% and 42% of households respectively. At the time of distribution, households had been encouraged to build a stand for the handwashing facilities and this had been done in more than 83% of households in all study arms. Stands were created from locally available materials such as wood. In IA3-mirror, 77% of households had the mirror hung alongside the handwashing facility at the point of follow-up. Presence of soap in the household was high across all study arms (96-100%).
Table 2. Results from household survey on hygiene proxy indicators from the four study arms in an exploratory pilot study in Moyale, Ethiopia.
Variable
|
Control arm
n=50
|
Intervention Arm 1: Liquid
n=50
|
Intervention Arm 2: Scented
n=51
|
Intervention Arm 3: Mirror n=52
|
Hygiene Proxy indicator (Handwashing facility with soap and water present), % (n)
|
64% (32)
|
44% (22)
|
25% (13)
|
40% (21)
|
Handwashing facility available on premises, % (n)
|
96% (48)
|
92% (46)
|
88% (45)
|
92% (48)
|
Water available at handwashing facility, % (n)
|
92% (44)**
|
93% (43)**
|
87% (39)**
|
83% (40)**
|
Soap available at handwashing facility, % (n)
|
66% (33)**
|
44% (22)**
|
27% (14)**
|
42% (22)**
|
Constructed a stand or other mechanism to raise the facility off the ground, % (n)
|
92% (44)
|
91% (42)*
|
87% (39)
|
83% (40)
|
Mirror available by handwashing facility, % (n)
|
0% (0)
|
0% (0)*
|
0% (0)
|
77% (37)
|
Soap available in household, % (n)
|
98% (49)
|
100% (50)
|
96% (49)
|
98% (51)
|
Types of soap available in household, % (n)
|
|
|
|
|
Liquid soap
|
16% (8)
|
92% (46)
|
22% (11)
|
27% (14)
|
Scented bar soap
|
26% (13)
|
26% (13)
|
51% (26)
|
17% (9)
|
Laundry soap
|
72% (36)
|
66% (33)
|
63% (32)
|
81% (42)
|
Normal bar soap
|
88% (44)
|
70% (35)
|
76% (39)
|
71% (37)
|
Number of households reporting that they have enough soap to meet their family’s needs, % (n)
|
45% (22)*
|
52% (26)
|
45% (23)
|
48% (25)
|
Number of households reporting that soap is affordable for them, % (n)
|
41% (20)*
|
51% (25)*
|
52% (26)*
|
42% (22)
|
* Percentages were estimated from slightly smaller denominators than those shown at the top of the table for the following variables due to unanswered survey questions/missing values.
** Percentages were estimated from the total number of handwashing facility present in the respective study arm.
Reported benefits of soap
Respondents gave open-ended answers in the survey to what the benefits of soap were (Table 3). Despite the distribution of hygiene kits, a large number of respondents, 45-54% across all arms, still reported that they felt that their family did not have sufficient access to soap and that it was not affordable for them. When asked about the advantages of soap, most respondents freely reported that handwashing with soap could protect health or prevent disease (Table 3). A few respondents particularly mentioned diarrhoea as a disease that can be prevented by HWWS. Respondents also listed cleanliness and comfort as advantages of HWWS.
Table 3. Advantages of soap freely listed by participants in the household survey in the 4-arm exploratory pilot study in Moyale, Ethiopia.
Advantages listed by respondents, % (n)
|
Control arm
n=50
|
Intervention Arm 1: Liquid
n=50
|
Intervention Arm 2: Scented
n=51
|
Intervention Arm 3: Mirror n=52
|
To keep healthy
|
48% (24)
|
44% (22)
|
35% (18)
|
48% (25)
|
To remove dirt and maintain cleanliness and hygiene
|
34% (17)
|
42% (21)
|
53% (27)
|
31% (16)
|
To remove germs and protect against disease in general
|
34% (17)
|
48% (24)
|
51% (26)
|
46% (24)
|
To feel comfortable
|
8% (4)
|
4% (2)
|
8% (4)
|
2% (1)
|
To prevent antibiotic resistance
|
6% (3)
|
4% (2)
|
0% (0)
|
4% (2)
|
To prevent diarrhoea
|
4% (2)
|
2% (1)
|
6% (3)
|
0% (0)
|
To prevent malnutrition
|
2% (1)
|
2% (1)
|
0% (0)
|
2% (1)
|
To reduce absence from school
|
0% (0)
|
2% (1)
|
0% (0)
|
0% (0)
|
Don’t know
|
0% (0)
|
2% (1)
|
4% (2)
|
0% (0)
|
Observations of handwashing
In total, 1458 opportunities for handwashing were observed by our research team (Table 4). Out of those opportunities, HWWS was observed only 218 (14%) times. HWWS prevalence is presented in (Table 4). IA1-Liquid had the highest prevalence of HWWS overall for all key times for HWWS. In this study arm, HWWS prevalence was 20% but exploratory statistical analysis indicates that this prevalence was not significantly different when compared to the control group. In IA2-Scented, HWWS prevalence at end line was 7% lower than in the control arm, indicating that distribution of scented soap may have had a negative effect on HWWS prevalence. Exploratory statistical analysis indicates that this negative effect may be significant when compared to the control arm.
Table 4. Observed handwashing behaviour at all key times (after defecation, before preparing food, before eating, before serving/feeding another person food, after cleaning a child’s bottom).
Study Arm
|
Total number of observed possibilities for handwashing
|
Handwashing prevalence % (n)
|
P Valuea
|
Intervention Arm 1: Liquid (n=50)
|
409
|
20% (82)
|
0.348
|
Intervention Arm 2: Scented (n=51)
|
385
|
10% (40)
|
0.005
|
Intervention Arm 3: Mirror (n=52)
|
302
|
11% (33)
|
0.018
|
Control arm (n=50)
|
362
|
17% (63)
|
|
aPearson Chi-square test.
Reported barriers to handwashing from focus group discussions
A total of 33 people participated in the six FGDs. When asked about current barriers to HWWS the most common challenge was the affordability of soap. Participants made it clear that knowledge was not the problem as most people knew about the importance of handwashing to protect them against disease and to maintain their health.
“Everyone now knows that it’s important to wash our hands with soaps, but affording it [soap] is the problem” (Woman, FGD2)
“In the old times, the problem was illiteracy. Nowadays though, everyone including the kids have the knowledge [about handwashing]. But people are different, in that some are tidy while others don’t care a lot about cleanliness. But I can generalize and say the main problem is the lack of money for soap affordability.” (Man, FGD1)
“There are variety of challenges, among which affording soap is an issue. People also don’t buy soaps on a regular basis in the same way they buy other home goods when they run out of it. So people also don’t look at soaps as a priority” (Man, FGD3)
In addition to affordability, forgetting to HWWS or only doing it when absolutely necessary were mentioned as reasons for not washing hands regularly. Some people reported only washing their hands when they were visibly dirty, or when participants had been in contact with chemicals such as paint.
“Some cannot afford soaps. The other factor is people’s style of life. Some are not used to washing with soap after using the toilet, they don’t remember to wash their hands with soaps after normal routines except when we deal with some rare activities where the need of using soap become a necessity, like after painting.” (Man, FGD3)
IDPs shared that humanitarian organisations would sometimes provide soap in hygiene kits and do hygiene promotion in the area. The irregularity of distributions appears to have created variations in handwashing behaviour, since when distributions ceased populations often resorted to handwashing with ash or not handwashing at all. Some mentioned long distances from their house to shops and markets as barriers to purchasing soap regularly.
“We do not get soap distributions regularly. We used to wash our hands properly when the supplies were given to us, but once they were done with the distributions, we could not go out and buy soap because of money issues.” (Man, FGD4)
Water scarcity was also a common challenge raised, with participants explaining that water was prioritised for other household tasks rather than HWWS.
“In this zone when water becomes scarce, people don’t even wash their faces, let alone washing hands, so water shortage could be a reason” (Man, FGD1)
“Due to drought, famine, and conflict in our area, there is a water and money shortage which means we don’t have enough water for hand washing and money for affording soap, even though we have the knowledge about cleanliness. (Man, F1)
Ranking of different types soap by focus group discussion participants
Table 5: Results from soap ranking activity where FGD participants were asked to rank different types of soap against a list of criteria describing different qualities of the soap (1= the highest ranking and 6= the lowest ranking).
|
Desirability
|
Pleasantness
|
Long lasting
|
Familiarity
|
Something that I really would want to use
|
A soap the kebele leader would be likely to use
|
Effective at killing germs
|
Easy to use
|
Water saving
|
Gender
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
Liquid soap
|
5
|
1
|
3
|
3
|
4
|
2
|
5
|
4
|
3
|
3
|
6
|
3
|
3
|
2
|
1
|
1
|
6
|
1
|
Scented bar soap
|
1
|
2
|
1
|
1
|
2
|
1
|
2
|
5
|
1
|
1
|
4
|
6
|
6
|
3
|
5
|
3
|
1
|
2
|
Normal soap
|
3
|
3
|
2
|
4
|
3
|
4
|
4
|
3
|
2
|
2
|
2
|
5
|
4
|
4
|
4
|
2
|
2
|
5
|
Antibacterial soap
|
2
|
4
|
5
|
2
|
5
|
5
|
6
|
6
|
5
|
4
|
5
|
4
|
1
|
1
|
3
|
5
|
4
|
3
|
Low-cost bar soap
|
6
|
6
|
6
|
6
|
6
|
6
|
1
|
1
|
6
|
6
|
1
|
1
|
5
|
6
|
2
|
6
|
5
|
6
|
Laundry bar soap
|
4
|
5
|
4
|
5
|
1
|
3
|
3
|
2
|
4
|
5
|
3
|
2
|
2
|
5
|
6
|
4
|
3
|
4
|
Table 5 summarises the results from the soap ranking activity, in which FGD participants were asked to rank each soap against a number of criteria. They were asked to consider the use of the soap for handwashing only rather than also for other purposes. The scented bar soap came out the highest overall, ranking first or second for both women and men for five criteria; desirability, pleasantness, long-lasting, ‘A soap I would like to use’ and water saving. Participants from one FGD (F1) remarked that they enjoyed the smell of the scented bar soap and that they had not seen a green bar of soap before. However, one participant said that nice smelling bar soap might be a ‘waste’ in their community because they regularly touch and come into contact with animals which have an unpleasant smell. Men and women both found the liquid soap easy to use, and believed that the antibacterial soap was the most effective in killing germs, but ranked these soaps inconsistently in other categories. The low-cost bar soap was most familiar to the participants as it was available to purchase in most local shops and markets, but otherwise ranked consistently poorly. It was ranked as the soap that utilised the most water, was least pleasant to use and was consumed the quickest. Men and women generally ranked soaps similarly, but had mixed attitude’s on liquids soap’s ability to be water saving. On this criterion, men considered liquid soap to be the most water saving while women considered it to be the soap that wasted the most water. There were mixed attitudes towards the use of laundry soap for handwashing. Laundry soap was ranked highest by women has the soap that would last the longest, however the women did not find this type of soap easy to use.
Perceptions about the mirrors based on FGD discussions
The last part of the FGD aimed to understand community perceptions towards mirrors placed in close proximity to handwashing facilities. The mirror was very well received by the participants who valued the size of the mirror, reflecting that it would allow them to see their entire bodies and not just the face. The only thing participants listed as a concern about the mirror was that they did not think it would be affordable to them should they have to buy it themselves.
“This mirror is big enough to show the all of my body. This is why we say it’s so good.” (Woman, FGD2)
“I like the way it allows me to see my whole self, what I don’t like about it is the money I lack to get such a mirror,” (Man, FGD4)
When asked where they would place a mirror like this, most participants said that a nice mirror like this should be kept inside the house. Participants expressed concerns about keeping the mirror outside because they believed that the reflection of the sun shining onto the mirror was harmful to their health. They were also concerned that it might get stolen or that children or animals might break it.
“When it is sunny, the mirror gives out a reflection which is not good for our health. It might get stolen too, cattle might break it also” (Man, FGD3)
“It should not be kept outside because it might get broken, it is meant to be inside the house.” (Man, FGD3)
The majority of participants said they would not want to keep the mirror by the handwashing facility, as this was often located near the toilet, some distance from the house.
“Firstly, that place is at a distance from our house. Secondly, children might just grab it away, the other factor is that our toilet has no suitable wooden place where we can hang the mirror.” (Woman, FGD7)
Nonetheless, participants did see that there could be some benefits by keeping the mirror next to the handwashing facility. Some participants said keeping the mirror close to the toilet would allow them to identify dirt and therefore make cleaning themselves an easier task. Some also reported that if they had two mirrors, they would consider keeping one in the household, and one by the handwashing facility.
“Yeah it has a benefit and that is that after toilet usage we would stand there to see which part to clean and wash our hands and our face.” (Man, FGD4)
“It shows me the cleanliness of my body, for example, after toilet usage, it shows me whether I have gotten rid of the dirt or not.” (Man, FGD1)
“It can show you dirt. Had we had other extra mirrors, we would spare one for that spot.” (Woman, FGD4)