Date Published: May 6, 2019
Publisher: Public Library of Science
Author(s): Sian White, Jessica F. Petz, Kifle Desta, Torben Holm Larsen, Jerome T. Galea.
Diarrhoeal diseases are a major contributor to morbidity and mortality in humanitarian crises. Handwashing with soap may reduce diarrhoea by up to 47%, however, the circumstances associated with displacement make it challenging for crisis-affected populations to be able to wash their hands with soap. The Supertowel is an alternative hand-cleaning product, proven to be as efficacious as handwashing with soap. The Supertowel is a micro-fibre towel with an anti-microbial treatment. When dipped in water it is capable of removing and killing pathogens from hands. This study aims to assess whether the Supertowel could be an acceptable and feasible product for crisis-affected populations.
The study took place in an Eritrean refugee camp located in Tigray state in Ethiopia. We used a mix of qualitative methods to understand use and acceptability, including baseline observations (n = 13), behaviour trials involving interviews at three time points (n = 19) and focus group discussions (n = 3). We thematically analysed data from interviews and discussions.
Participants indicated that the Supertowel was convenient, easy to use and saved them water and money. All households participating in the behaviour trials had at least one Supertowel in use at the end of the trials (follow-up visit two). In discussions participants reported that the Supertowel was more desirable than comparable hand cleaning products. In interviews, trial participants explained that the product enabled them to clean their hands at times when they might not normally bother. The research also identified some issues with the smell of the Supertowel and its intuitive use.
The Supertowel was found to be an acceptable and useful hand-cleaning product that could complement soap use in crisis contexts. This pilot study also identified areas of future research including the need to compare different distribution models for the Supertowel (distribution in hygiene kits compared to distribution with an accompanying communication package) and to evaluate its use at scale over a longer time period.
Humanitarian crises often displace populations and relocate them into crowded environments. During crises it is also common for water and sanitation infrastructure to be damaged and health systems to be weakened or overburdened. These conditions are ideal precursors for the spread of pathogens through the faecal-oral route. It is estimated that in camp situations, 40% of all mortality during the acute phase of a crisis is due to diarrhoeal disease . Evidence from non-emergency settings indicates that handwashing with soap may reduce diarrhoea by 23–47% [2, 3]. However, in emergencies water is typically scarce and distribution of soap is complex and has had mixed results on improving handwashing behaviour [4–6]. Where soap and water are available in crises contexts they are typically not conveniently available for handwashing and are often prioritised for other household tasks (e.g. bathing, laundry and dishwashing) [5, 7]. Recent literature reviews have cited the many challenges and limitations of hygiene promotion in emergency settings [8, 9]. This study explores whether an alternative hand-cleaning product could be acceptable and feasible for crisis-affected populations.
Having proved the efficacy of the Supertowel in controlled conditions, this study aimed to assess the acceptability and feasibility of the product in a humanitarian context where water is scarce and ongoing soap distribution is challenging. The study also aimed to provide opportunities for crisis-affected populations to generate ideas about how the product could be improved to better meet their needs.
After conducting baseline observations in 13 households the research team concluded that a degree of saturation had been reached in relation to understanding current hand-cleaning practices. All of these 13 households agreed to participate in the behaviour trials as well. A further six households were sampled to participate in the behaviour trials only, for a total of 19 households. Table 1 summarises the socio-demographic characteristics of all households, and individuals. Eighteen households perceived both water accessibility and soap availability and affordability to be major issues in the camp. However, soap of some kind was present in all 19 households.
Baseline observations and discussions with participants confirmed our assumptions about the challenges of practicing handwashing with soap in a camp context. Not only did people report having insufficient access to water and soap, but their inability to practice handwashing was compounded by condensed living environments, a lack of social support for handwashing and an absence of handwashing facilities to cue handwashing behaviour or make it more convenient. Studies of handwashing behaviour in other locations have identified similar barriers [19, 22, 24–26] The Supertowel was generally well liked and seen as a product which could adequately meet hygiene needs in humanitarian contexts. Participants in the behaviour trials trusted the efficacy of the product from the outset and were able to recognise its potential benefits, including that it would save water and the amount of money spent on soap. As the behaviour trials continued, participants reported that their initial impressions of the product were consistent with their actual experience of using it. They also reported increased frequencies of handwashing associated with the ease of using the Supertowel. Wetness rankings supported this by suggesting that 19 out of 19 (100%) households had at least one Supertowel in use (that was wet or damp) at the time of follow-up visit two. Findings from the focus group discussions confirmed the acceptability seen in the behaviour trials. Both men and women ranked the Supertowel highly against all criteria and substantially better than the soap that was being distributed by camp authorities. Adaption to this new mode of hand-cleaning appeared to occur quickly, with some individuals stating they felt ‘addicted’ to the towel just 12 days after the initial distribution. Many participants reported using the SuperTowel for reasons other than hand cleaning, but that this did not deter them from subsequently using it on their hands. Alternative uses included cleaning surfaces and dishes, face cleaning, and bathing.
By triangulating data from a range of qualitative methods we were able to demonstrate that the Supertowel is an acceptable product and a feasible alternative to soap in contexts where handwashing is challenging. Use of the Supertowel was high (90% of households at follow-up visit one, and 100% of households at follow-up visit two), and self-reported adoption to the new behaviour occurred quickly. This pilot study demonstrated the value of engaging crisis-affected populations in the design of products which may be used by them in the future. Specifically, this process identified required modifications to the Supertowel design, such as improving the carry bag and addressing smell issues. The study also identified areas of future research including the need to compare different distribution models and to evaluate the use of the Supertowel at scale, over a longer period of time, and using observed measures for hand-cleaning.