Thank you Emily for initiating a discussion on a niche and such an under-researched area (as the number of studies you could find clearly tells).

I am wondering if one could bracket epidemics or pandemics and natural disasters and crises such as being in refugee camps,  together under humanitarian crises? The distinction being displacement (temporary or permanent) from one's natural setting and therefore difference in control one has or perceives to have over the situation. 

Regards
paresh

Hi Elisabeth,

Thank you for your comment. Apologies that it has taken me this long to respond. Thank you for recommending the paper, I had found it elsewhere and used it in my thesis. I have actually finished writing and submitted my literature review. I'll briefly summarise the findings below.

Previous research showed 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 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.

Regarding anxiety and handwashing, 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.

While looking at depression and handwashing, 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 ).

What I concluded from these findings was that 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.

If you'd like to know more, I wrote a blog about this research. The link can be found here: www.washem.info/news/what-do-we-actually...alth-and-handwashing or www.ircwash.org/blog/what-do-we-actually...alth-and-handwashing. If you get a chance to read it, I'd love to hear what you thought of it and if you have any questions. Additionally, I will be getting the grade and feedback of my thesis in December and will be working towards publishing this after that.

Kind regards,
Emily Ghassemi

Hi Kris,

Thank you for the recommendation! I'll have a look at the book.

Kind regards,
Emily

Slightly off topic, but this book review by an US-based psychologist has some interesting thoughts on psycho-social interventions in various settings and after emergencies: astralcodexten.substack.com/p/book-review-crazy-like-us

I have not read the book itself, but if you are interested in the general topic it sounds like a must read.

Hi Emily,

Welcome to the SuSanA discussion forum! I just noticed that your post didn't get a reply yet. That's a pity because it strikes me as an interesting topic. So I am posting here in this thread to get your post back to the top of the pile.

I also did a search for "mental health" here on the forum, using the search field above. You might have already done that search yourself. A few threads came up. Some dealt with mental health issues that were caused by lack of sanitation, which is not what you're after.

Then there was a post by Dan in May 21 ( here ) where he mentioned a paper on this topic, perhaps it's relevant:
Does poor mental health change the influence of interventions on handwashing in a vulnerable population of rural Malawi? The key role of emotions
iwaponline.com/washdev/article/11/3/350/...nge-the-influence-of

How far along are you with your literature review at this stage? Have any trends emerged yet? Do tell us more.

Regards,
Elisabeth

Dear all, 

I am working on a literature review for my dissertation on the following topic: Mapping the association between mental health and displaced people’s perceived and actual ability to practice hygiene-related behaviors in complex crisis-affected settings. My project topic was informed by prior research done by LSHTM and ACF and it is hoped that the review will contribute to shaping the future work of humanitarian organizations in this area. 

I will be conducting a scoping literature review on the topic using the methodological framework proposed by Arksey and O’Malley (2005). This framework involves a consultation exercise among key stakeholders, in my case from the Global WASH Cluster and the Mental Health and Psychosocial Support Sub-Cluster, to identify additional references such as grey literature and potential studies to include. For this reason, I am reaching out to you. 

The research questions I am addressing are listed below. 
 

1. What is known about the association between mental health and people’s perceived and actual ability to practice handwashing behavior in humanitarian crises?
2. How do different mental health conditions impact different elements of handwashing behavior?
3. Are there opportunities for integrating mental health and hygiene programs?
4. What are the gaps in the literature? 
5. What are areas for future research?

 
My request to you is do you have additional references such as grey literature and potential studies that I can include in my scoping review? I am interested in anything related to:
 
Mental health and psychosocial support (specifically post-traumatic stress disorder (PTSD), depression, or anxiety, emotional distress, personal wellbeing, or any other psychological disorders) in relation to Hygiene behavior (handwashing, handwashing with soap, hand cleaning with sanitizer, hand disinfection, or handwashing with ash) in humanitarian settings: (disasters, outbreaks, conflicts, or complex crises, particularly in low- and middle-income countries).
 
I am reviewing literature from databases such PubMed, MEDLINE, EMBASE, Global Health, and the LSHTM library. I will also identify grey literature through displacement-relevant portals including the International Rescue Committee, United Nations Children’s Fund WASH, United Nations High Commissioner for Refugees, RAND, the Centers for Disease Control and Prevention WASH, International Committee of the Red Cross, and World Bank Water. 
 
Your participation will be a valuable addition to my research and allows me to gain a wider insight into this topic. 
 
Please let me know if you can refer me to anything useful or if you can connect me to others I could ask. Thank you in advance.  
 
Kind regards, 
 
Emily Ghassemi