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      How is hygiene behaviour affected by conflict and displacement? A qualitative case study in Northern Iraq

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          Abstract

          This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different post-conflict settings in Northern Iraq–a long-term displacement camp, a short-term displacement camp, and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and, of these, 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical, psychological, social and economic circumstances of displaced populations. Future hygiene programmes in post-conflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency, build on adaptive norms, create an enabling environment and which are integrated with other aspects of humanitarian response.

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          Most cited references65

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          Faking it: Social desirability response bias in self-report research

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            Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis.

            To quantify the effect of hand-hygiene interventions on rates of gastrointestinal and respiratory illnesses and to identify interventions that provide the greatest efficacy, we searched 4 electronic databases for hand-hygiene trials published from January 1960 through May 2007 and conducted meta-analyses to generate pooled rate ratios across interventions (N=30 studies). Improvements in hand hygiene resulted in reductions in gastrointestinal illness of 31% (95% confidence intervals [CI]=19%, 42%) and reductions in respiratory illness of 21% (95% CI=5%, 34%). The most beneficial intervention was hand-hygiene education with use of nonantibacterial soap. Use of antibacterial soap showed little added benefit compared with use of nonantibacterial soap. Hand hygiene is clearly effective against gastrointestinal and, to a lesser extent, respiratory infections. Studies examining hygiene practices during respiratory illness and interventions targeting aerosol transmission are needed.
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              Disgust as an adaptive system for disease avoidance behaviour

              Disgust is an evolved psychological system for protecting organisms from infection through disease avoidant behaviour. This ‘behavioural immune system’, present in a diverse array of species, exhibits universal features that orchestrate hygienic behaviour in response to cues of risk of contact with pathogens. However, disgust is also a dynamic adaptive system. Individuals show variation in pathogen avoidance associated with psychological traits like having a neurotic personality, as well as a consequence of being in certain physiological states such as pregnancy or infancy. Three specialized learning mechanisms modify the disgust response: the Garcia effect, evaluative conditioning and the law of contagion. Hygiene behaviour is influenced at the group level through social learning heuristics such as ‘copy the frequent’. Finally, group hygiene is extended symbolically to cultural rules about purity and pollution, which create social separations and are enforced as manners. Cooperative hygiene endeavours such as sanitation also reduce pathogen prevalence. Our model allows us to integrate perspectives from psychology, ecology and cultural evolution with those of epidemiology and anthropology. Understanding the nature of disease avoidance psychology at all levels of human organization can inform the design of programmes to improve public health.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: VisualizationRole: Writing – original draft
                Role: Funding acquisitionRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: InvestigationRole: ValidationRole: Writing – review & editing
                Role: InvestigationRole: ValidationRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: MethodologyRole: Supervision
                Role: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                3 March 2022
                2022
                : 17
                : 3
                : e0264434
                Affiliations
                [1 ] Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [2 ] Operations Department, Action Contre la Faim, Paris, France
                [3 ] Independent Researcher, Nutrition and Dietetics Department, College of Medical Technology, Cihan University, Erbil, Kurdistan Region of Iraq
                [4 ] Independent Researcher, Dohuk, Kurdistan Region of Iraq
                [5 ] Geneva Centre of Humanitarian Studies, Université de Genève, Geneva, Switzerland
                Jhpiego, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0003-2402-6080
                Article
                PONE-D-21-15601
                10.1371/journal.pone.0264434
                8893612
                35239702
                7c81657f-99e9-4e0b-80cf-0095a57090fc
                © 2022 White et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 11 May 2021
                : 10 February 2022
                Page count
                Figures: 0, Tables: 4, Pages: 19
                Funding
                Funded by: US Bureau of Humanitarian Assistance
                Award ID: AID-OFDA-G-16-00270
                Award Recipient :
                Funding for this research was provided by United States Agency for international development’s Bureau of Humanitarian Assistance via grant number AID-OFDA-G-16-00270. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This grant contributed to the salaries of Sian White, Thomas Heath, Waleed Khalid Ibrahum and Dilveen Ihsan, but did not fully fund these.
                Categories
                Research Article
                Medicine and Health Sciences
                Public and Occupational Health
                Hygiene
                Physical Sciences
                Chemistry
                Chemical Compounds
                Salts
                Soaps
                Biology and Life Sciences
                Psychology
                Behavior
                Social Sciences
                Psychology
                Behavior
                Earth Sciences
                Geography
                Human Geography
                Social Geography
                Social Sciences
                Human Geography
                Social Geography
                Social Sciences
                Sociology
                Human Families
                Ecology and Environmental Sciences
                Natural Resources
                Water Resources
                Medicine and Health Sciences
                Epidemiology
                Medical Risk Factors
                Medicine and Health Sciences
                Gastroenterology and Hepatology
                Diarrhea
                Medicine and Health Sciences
                Clinical Medicine
                Signs and Symptoms
                Diarrhea
                Custom metadata
                Some relevant data are within the Supporting Information files. The transcripts of the interviews and group discussions are publicly available in redacted form via an open repository which can be accessed via the following citation: White, Sian (2021): Interviews and group discussions with displaced populations in Iraq on the determinants of handwashing behaviour. figshare. Dataset. https://doi.org/10.6084/m9.figshare.17263829. Observational data, visual data and data from handwashing demonstrations is not available because it is not possible to make this data anonymous.

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