Determinants of hand hygiene behaviours in internally displaced persons camps in flood-affected areas of South Sudan: a mixed-methods formative research study

In addition to longstanding conflicts, South Sudan has experienced devastating flooding in recent years, resulting in an ongoing humanitarian crisis. In early 2024, it was estimated that there were two million internally displaced persons (IDPs) in South Sudan, with camp residents amongst those most vulnerable to infectious disease outbreaks. Our aim was to understand determinants of hand hygiene behaviours and explore existing hygiene programs in IDP camps in flood-affected areas of South Sudan. A mixed method approach was used to collect data in four IDP camps in Bentiu county, Unity State, in May to June 2023. Methods included: key informant interviews (n=5) with water, sanitation, and hygiene (WASH) implementing organizations, tours of WASH infrastructure in camps, focus group discussions (n=12) with camp residents disaggregated by age, gender, and disability status. Lastly, 50 camp residents were asked to participate in a brief survey and to demonstrate their handwashing behaviour in their current situation and in a hypothetical scenario if less water was available. We found that camp residents mostly washed hands with water only, with some using soap when available. Women were perceived as more likely to wash their hands. Residents commonly washed their hands after visiting the toilet, and before and after eating. Drivers of handwashing included visibly dirty appearance, smell, or a desire to feel fresh and clean. The main barriers to handwashing included a lack of soap, water, buckets, and other handwashing materials. Flooding affects handwashing behaviours in multiple ways, such as increased pressure on limited facilities due to IDP influxes and submerged water points. Handwashing using potentially contaminated flood water was also reported. Extreme weather events such as floods are predicted to increase in frequency and intensity with climate change - thus finding ways to sustainably improve handwashing in these changing contexts is essential.