Effect of a novel hygiene intervention on older children’s handwashing in a humanitarian setting in Kahda district, Somalia: a cluster-randomised controlled equivalence trial

Introduction: Improving handwashing with soap (HWWS) among children in humanitarian emergencies has the potential to reduce the transmission of several important infectious diseases. However, there is limited evidence on which approaches are effective in increasing HWWS among children in humanitarian settings. One recent innovation – the “Surprise Soap” intervention – was shown to be successful in a small-scale efficacy trial in a humanitarian setting in Iraq. This intervention includes soap with embedded toys delivered through a short household session comprising a glitter game, instruction of how and when to wash hands, and HWWS practice. Whilst promising, this approach has not been evaluated at programmatic scale in a complex humanitarian setting. Methods: We conducted a cluster-randomised controlled equivalence trial of the Surprise Soap intervention in IDP camps in Kahda district, Somalia. Proportionate stratified random sampling was employed to recruit 200 households, with at least one child aged 5-12, across the camps. Eligible households were randomly allocated to receive the Surprise Soap intervention (n=100) or an active comparator handwashing intervention in which plain soap was delivered in a short household session comprising standard health-based messaging and instruction of how and when to wash hands (n=100). The primary outcome was the proportion of pre-specified occasions when HWWS was practiced by children aged 5-12 years, measured at baseline, 4-weeks, 12 weeks, and 16 weeks post invention delivery. Results: HWWS increased in both groups (by 48 percentage points in the intervention group and 51 percentage points in the control group, at the 4-wee follow up), however, there was no evidence of a difference in HWWS between the groups at the 4-week (adjusted RR (aRR)=1.0, 95% CI 0.9–1.1), 12-week (aRR=1.1, 95% CI 0.9–1.3), or 16-week (aRR=1.0, 95% CI 0.9–1.2) follow-up. Conclusions: In a complex humanitarian setting, where soap availability and past exposure to handwashing promotion was low, it appears that well-designed targeted handwashing interventions can increase child HWWS and potentially reduce disease risk, but the Surprise Soap intervention offers no marginal benefit that would justify the additional costs.