PONE-D-19-25323

The determinants of handwashing behaviour among internally displaced people in two camps in the Kurdistan Region of Iraq

PLOS ONE

Dear Ms White,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I am returning your manuscript with three reviews. As you will see, all three reviewers highlight the need for research of this type to be carried out. However, all three express concerns regarding the methodology - specifically the identification and classification of "doers" and "non-doers", the data analysis - specifically the statistical tests used and the interpretation of the data. More detail regarding the camps (e.g. selection process; condition and NGO activities) and how this may have impacted behaviour is also requested. The concept of "emergent norms" is briefly discussed; was the length of time each mother had lived within the camp documented - did this differ between "doers" and "non-doers"? 

Whilst major revision of your manuscript is required, the reviewers acknowledge that studies on handwashing behaviour in humanitarian settings are lacking and so I encourage you to give their comments and suggestions due consideration. Please note, that on resubmission (if you choose to do so), the manuscript will have to go through the second round of review including if deemed necessary, a statistical review.

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Ginny Moore

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: TECHNICAL FEEDBACK

1. It is good to see a study on handwashing in humanitarian settings. The authors are well justified in their contention that this kind of research is needed.

2. The major technical limitation of the study lies with the identification of doers and non-doers. The authors report that “The screening process used a combination of self-reported handwashing behaviour and proxy measures of handwashing behaviour (such as the observed presence of used soap at the handwashing facility).” Self-reported handwashing is notoriously overreported:

https://journals.lww.com/jhqonline/Abstract/2007/07000/Reliability_and_Validity_of_Hand_Hygiene_Measures.5.aspx

Even direct observation of handwashing can overestimate actual handwashing: http://www.ajtmh.org/content/journals/10.4269/ajtmh.2010.09-0763

Script-based covert recall may be an alternative: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0136445

In this setting, proxy measures themselves may be inaccurate, and soap may be more available in a humanitarian setting than it would be normally.

Therefore, the study does not convincingly measure handwashing in a valid manner, and this throws into doubt the validity of classification of study participants as doers and non-doers.

3. “Perceived social norms - The perception that people important to an individual think that he/she should wash their hands with soap. Note that in theories such as the Focus Theory of Normative Conduct, this is the definition of injunctive norms. See: Cialdini, R.B.; Reno, R.R.; Kallgren, C.A. (1990). "A focus theory of normative conduct: Recycling the concept of norms to reduce littering in public places". Journal of Personality and Social Psychology. 58 (6): 1015–1026. doi:10.1037/0022-3514.58.6.1015.

4. Wrong statistical methods. In Tables like Table 8, the outcome or dependent variable “How likely is it that your child will get diarrhoea in the coming three months?” is an ordinal variable (See https://en.wikipedia.org/wiki/Ordinal_data for a definition) with three ordered responses. Appropriate measures of correlation include Kendall’s Tau-B, see https://en.wikipedia.org/wiki/Ordinal_data#Bivariate_statistics. It is inappropriate and incorrect to calculate a p-value for each row of the table. One single p-value and measure of association should be calculated with a statistical test like Kendall’s Tau-B. The same applies to Table 6 and 7.

5. In the absence of accompanying qualitative interview and observation data, it is difficult to draw any conclusions about why people do or do not wash their hands.

MINOR SPELLING AND GRAMMAR ISSUES

1. Please do a spell-check e.g. there are three errors here on the first page: “This [research] was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the study authors and do not necessarily reflect the views of USAID or the United States Government. A grant from the Office of U.S. Foreign Disaster Assistance was [received] by SW (award number AID-OFDA-G-16- 00270). Funder website: https://www.usaid.gov/who-we- are/organization/bureaus/bureau-democracy-conflict-and-humanitarian- assistance/office-us. The funders played no role in the study design, data collection, analysis, decision to publish or [preparation] of the manuscript.”

2. Line 289 – delete ‘of’ or reword that part of sentence

3. Line 388 – change subtler to more subtle

4. Line 397 – remove comma

Reviewer #2: Thank you for this interesting work. Overall, this is well written and useful for the humanitarian sector.

A good edit of the intro, methods, and results is needed; I thought the discussion was particularly well written and organized.

Something that I felt was missing was the discussion of WASH activities in the camps and previous/current hygiene promotion. NGO presence and activities need to be explained. By not describing NGO activities, the assumption is that NGO activities, promotion or distribution of materials or cash/vouchers have no impact on actions - I believe that to be rather significant and must be addressed.

Differences were mentioned briefly about the camps, but more analysis should be presented. If the different camps are actually similar, would combining the data sets provide a better opportunity for significant results.

How the camps were selected from what I would assume to be be dozens of camps needs to be explained.

Within the results there were several interesting findings (significant or not) that would be against logical assumptions, i.e. non-doers thought washing their hands would make them safer compared to doers (or something along those lines). While not significant, some explanation should be given or rationalized, especially since it seemed to occur several times.

Detailed comments:

Line 52-3: Strong statement. Please reference. Limited water availability or lack of soap could also be reasons. 

Line 64: Please be explicit about 'this research gap'

Methods: Please explain how these camps were selected, assuming this is a clear rationale. 

Line 83: .'..still experiencing trauma' - While this is likely the case, please avoid sweeping statements that are beyond the research.Line 84: Please be more clear on the camp conditions meeting the Sphere standards and temperature is not a Sphere standard. This paragraph should be revised and focused on camp conditions and population demographics. The high standard of living and accustomed to flush toilets is useful, but taking away electronics etc. is not relevant. 

Line 100: Who (what organization) was doing hygiene promotion? The approach should be described and is an obvious factor in beneficiaries hygiene activities. One camp needing to buy soap could also be a huge factor compared to 'in-kind' distributions. 

Line 118-122: These sentences are not relevant

Line 144: Some words required brainstorming - how can you be sure the beneficiaries understood the questions?   Line 193: So, someone describing 2 times washing their hands would be a non-doer? Or someone who described washing each of th3 5 time points, but ran out of soap would also be a non-doer? 

Line 210: Please state the statistics with p-value.

Results: Are the camps comparable? Was analysis conducted to determine they were similar?

Result tables should be better organized to highlight that results are by camp. 

Table 4: the only significant finding thus far is that non-doers state reasons why more than doers. Please explain or discuss. 

Line 252 Social Norms - results are presented differently. Please be consistent and give percentages over absolute numbers because its not clear what the same size is. 

Line 292 table: Doers say child very likely to get sick if they wash at the 5 critical times. Things like this are odd - some explanation should be given. 

Line 299: Please give stats. 

Line 319: God's will being a reason people get sick is a pretty large factor. 

Line 336: To me, it seemed like there were little similarities. No topic was significant in both camps correct?

Reviewer #3: This paper provides a practical assessment of the determinants of handwashing behaviour among internally displaced women who had a child under the age of five in two camps in the Kurdistan Region of Iraq . This is a topic for which there is a substantial need for research, and it is encouraging to see the authors taking on the challenge of contributing to this gap in evidence. Generally speaking, this is a very clear paper that I would recommend for publication with some revisions and additions.

The title of the does not represent the study population. The study team administered the questionnaires to “women who had a child under the age of five” but authors used “internally displaced people” in the title. Authors should change the study title to make it clear. The introduction could be a bit more comprehensive in terms of contextualizing the research based on existing evidence. The methods section is straightforward but should add some missing references. The results/discussion section is solid, though Table 2-8 in particular had 2 unnecessary column and should be removed from each table. The conclusion is quite vague and should be bolstered with more specific recommendations based on the results of this study.

Below I have provided a few points which should be addressed:

1. The introduction could be a bit more comprehensive in terms of contextualizing the research based on existing evidence.

2. In the abstract in line 38, the terminology "demographics" is used. It would be good to use “socio-demographics”.

3. Line 66-68: Authors should remove this "In turn, it is hoped that an increased understanding of behavioural determinants will allow humanitarians to design more acceptable and effective handwashing promotion programmes "

4. Line 82-83: The authors should provide reference for this “All participants had been exposed to extreme violence in the past three years and many were still experiencing trauma at the time of this research”.

5. Line 90-91: The authors should provide reference (s) for this “Many of the residents had come from urban or peri-urban areas and were used to a relatively high standard of living prior to the conflict.

6. The title of the does not represent the study population. The study team administered the questionnaires to “women who had a child under the age of five” (Line 149) but authors used “internally displaced people” in the title. Authors should change the title.

7. Line 173: “to maintain quality and identify any missing data” Authors should make it clear how they maintain the quality of data and what they actually had done it they could identify any missing data.

8. Table 2-8 had 2 unnecessary column and should be removed from each table.

9. The conclusion is quite vague and should be bolstered with more specific recommendations based on the results of this study.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq

PONE-D-19-25323R1

Dear Dr. White,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Ginny Moore

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

You will see that Reviewer #2 has made a couple of minor suggestions that you may wish to take into consideration if you are required to make any technical amendments to your manuscript. Please also clarify the result presented in lines 257-8 (that when citing positive consequences of handwashing there were no significant differences between groups) as Table 4 (camp 1) suggests otherwise (to get rid of dirtiness p=0.042*).  

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I found the paper to be very well written - especially the discussion and conclusion. Thank you for your hard work.

A few comments:

The objective is a bit unclear. Is it to understand the barriers for handwashing or to compare the Barrier Analysis with other tools? It seems to flip back and forth in the intro/methods.

Line 220: Why is n=156? Wouldn’t it be 180?

Line 272: Please explain: “non-doers were 18% more likely than doers to report a lack of 273 negative consequences (doers = 80%, non-doers= 98%, p=0.008)”

In the results, the descriptions seem to go from ‘doers and non-doers’ – to more then more general ‘people’ or C1 and C2 – obviously those are different groups, and reporting 18% of XXX can mean very different things depending on the specific description. Please be aware that can be difficult for the reader.

Line 447: There are 2 periods.

Reviewer #3: Authors have adequately addressed my comments and I would like to recommend this paper for publication

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Reviewer #2: No

Reviewer #3: No