Published on: 15/09/2021
Findings from a scoping literature review on handwashing and mental health in humanitarian crises.
Over the summer, I was an intern at IRC while simultaneously working on my Master’s thesis. I really wanted to get practical experience in the field of WASH while doing research on this at the same time. My thesis sought to map what is known about the link between mental health and handwashing in humanitarian crises. The topic arose from ongoing work being done in a collaboration project between the London School of Hygiene and Tropical Medicine and Action Contre le Faim known as WASH’Em. Below, I introduce the topic, layout the findings, and suggest next steps.
Did you know that handwashing behaviour could prevent an impressive one million infectious disease deaths globally, each year? Yet despite the existence of an effective preventive measure, practising this requires effort, time, and a strong internal motivation, which may be affected in those experiencing mental health disorders (White et al., 2020). Imagine you are one of the over 80 million people who were forcibly displaced in mostly low- and middle-income countries due to humanitarian crises including armed conflicts, epidemics, famine, natural disasters, and complex emergencies (UNHCR, 2020). You might be hosted in informal settlements, camps, or within host communities, where you face poor environmental health conditions due to overcrowding and limited infrastructure and resources. The consequences of these include an increased burden of endemic infectious diseases such as diarrhoeal disease and respiratory infections as well as more frequent and severe epidemics of WASH-related diseases such as cholera (Phillips et al., 2015). Experiencing such an impactful setting and a massive upheaval, could unsurprisingly, leave one with symptoms of poor mental health. Therefore, there is a need to investigate what is known about the association between mental health and people’s perceived and actual ability to practise hygiene-related behaviours in humanitarian crises.
Previous research has shown that depressive, anxiety, and post-traumatic stress disorders are the most common mental health issues encountered in humanitarian crises (Slekiene and Mosler, 2018). Beyond affecting a person’s quality of life, these disorders have also been found to impact hygiene behaviour, likely affecting the effectiveness of WASH promotion campaigns. In order to encourage people more to practice this pro-health behaviour and ensure that time and resources are not wasted, we need to know how to integrate mental health and WASH programmes to identify and support those who need mental health services.
A thorough search of peer-reviewed literature databases PubMed, Medline, Global Health, Embase, and the online library of the London School of Hygiene and Tropical Medicine yielded 13 relevant resources to be included for publication. External consultations with relevant humanitarian experts in the WASH and Mental Health and Psychosocial Support Sub-Cluster and searches of humanitarian-relevant portals yielded an additional four publications.
The eligible included studies were done in China, Iran, and Sierra Leona and researched the COVID-19 pandemic and the Ebola Virus Disease outbreak. These studies found that those with higher rates of anxiety were more likely to practise handwashing with soap behaviour. This could be because anxiety is a response elicited by the presence of a threat and the negative emotions that come with it. In general, this may have been a response that evolved to motivate us to undertake adaptive and protective behaviours (Perkins and Corr, 2014; Harper et al., 2020). Anxious people may be more vigilant or have more concerns about the disease, however, it may also be that increased vigilance led to the development of anxiety in those who were more heavily engaged in precautionary measures.
Studies done in China yielded mixed results, but the most common pattern was that those with higher rates of depression were less likely to wash their hands. Those with depression more frequently forgot to wash their hands, experienced less pleasure in handwashing, felt less guilty when not washing hands, and had less intention to wash their hands with soap (Slekiene and Mosler, 2018). Negative thought patterns, evaluations of the self, the environment, and the future; thoughts of worthlessness, and thoughts of death mean that handwashing is not a behaviour that is prioritised for a person experiencing depression.
As with depression, findings on the association between post-traumatic stress disorder (PTSD) and handwashing were mixed. During the COVID-19 pandemic, observing better hygiene practices was associated with lower rates of PTSD symptoms. But, in Sierra Leone, a country versed in the effects of war and a devastating Ebola outbreak, higher exposure to war was associated with more frequent handwashing, but PTSD symptoms specifically, were associated with less handwashing. More exposure to traumatic war experiences may mean that individuals have stronger survival skills or have become more risk-averse, thus practising more handwashing behaviour (Betancourt et al., 2016). Individuals experiencing PTSD symptoms might not be able to deal with their experiences in the same way, thus not showing this same positive relationship. Additionally, the prominence of the threat of disease may not be as great as that of war (Coetzee and Kagee, 2020).
The contradicting nature of emerging patterns suggests that researchers and practitioners need to explore this association further and get better at researching this. One way to improve researching this association is by improving outcome measurement and utilising more longitudinal and qualitative study designs. To address the former, improving the validity of outcome measurements through standardised and non-self-reported tools could mean spot checks for soap and water availability as well as promoting a common set of tools to evaluate the most common disorders in humanitarian settings. Similarly, more qualitative methods may provide a better insight into the perceived barriers to handwashing. More longitudinal approaches could aid in understanding causality in the association and help distinguish chronic disorders from acute disorders.
So, what are the next steps? Well, there are some key areas for integration of mental health and psychosocial support services (MHPSS), particularly in humanitarian responses. A first step should be incorporating mental health assessments in WASH surveys. Similarly, there is an opportunity for hygiene practitioners to be trained in mental health first aid to identify the needs of their target population. Through this, those requiring support can access this, improving not only quality of life, but also the effectiveness of handwashing interventions. Current approaches to research in humanitarian crises are still siloed in nature so establishing integrated working groups and communities of practice on WASH and MHPSS can be helpful to share key learnings, best field practices, and challenges experienced. Following this, though it is not the end-all-be-all, adapted technology-based interventions such as online or telephone-based Cognitive Behavioural Therapy can be useful for providing covert MHPSS during all types of humanitarian crises. Lastly, long-term investments should be made in public, local, and community-based MHPSS as preparedness and resilience help societies better respond to MHPSS needs.
Although I have finished and submitted my thesis, I look forward to publishing it. Please stay tuned for this.
Reviewed by Sian White (London School of Hygiene and Tropical Medicine)
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