Preventive Measures against Ebola and COVID-19 and Their Impact on Human Dirty-Hand Disease Mitigation in Côte d’Ivoire

Abstract

Hygiene is the most useful public health measure for preventing infections of important endemic and emerging diseases of global significance. This study aimed to assess the impact of these public health preventive measures on dirty hand diseases. A retrospective survey was conducted in the rural general hospitals of Taabo (south-central Côte d’Ivoire) and Marcory (urban Abidjan) to collect clinical data on dirty hand diseases in the patients’ records from 2013 to 2020. In addition, focus group discussions (N = 8) were conducted in the communities in both settings to identify the sociocultural and economic hindering or fostering factors that affected the adoption of and the compliance with handwashing and disinfection practices. A total of 3245 and 8154 patients’ records were examined in the general hospitals of Taabo and Marcory, respectively. Compared with women, men were more affected by typhoid fever (OR, 0.68 [95%CI, 0.53–0.88]) and influenza (OR, 0.87 [95%CI, 0.75–1]). Hygiene measures promoted during Ebola and COVID-19 outbreaks had no impact on the prevalence of typhoid fever in both settings; however, a positive impact was observed regarding influenza infections. Populations were aware of the importance of handwashing for public health but had difficulties adhering due to financial constraints, access to drinking water, and the absence or scarcity of handwashing facilities.

1. Introduction

The 21st century has witnessed outbreaks of the Ebola virus disease (EVD) and the emergence of the coronavirus disease 2019 (COVID-19)—both major health crises of international significance—the etiological agents of which are the Ebola virus Zaire strain and SARS-CoV-2, respectively [1]. In addition to these diseases, dirty-hand disease due to inadequate access to water, sanitation, and hygiene (WASH) constitute the main public health problems. Dirty hand diseases include cholera, typhoid fever, and influenza. In 2015, across the globe, the annual incidence of cholera was estimated at 1.3–4.0 million cases, resulting in 21,000 to 143,000 deaths worldwide [2]. In 2019, approximately 99,000 to 200,000 deaths globally from lower respiratory tract infections were directly caused by influenza [3].

While most dirty hand diseases have largely been eliminated in high-income regions that have developed modern WASH facilities, they remain a significant public health burden in low- and middle-income countries (LMICs) [4]. In 2016, approximately 829,000 deaths were attributable to WASH and 49.8 million disability-adjusted life years (DALYs) occurred from diarrheal diseases in LMICs [5]. In 2019, a comprehensive review by Marchello and Crump estimated the incidence of typhoid fever in Africa at 112.1/100,000 person-years [6].

In Sub-Saharan Africa, there is a paucity of published data on dirty hand diseases [7]. From 2011 to 2015, surveillance data in Ghana showed a typhoid fever incidence rate of 0.68–1.60% [8]. In Burkina Faso, the annual incidence rate was between 107 and 402 per 100,000 [9]. In Côte d’Ivoire, between 2002 and 2017, epidemiological surveillance of cholera recorded 8424 cases with 304 deaths, a fatality rate of 3.6%. Most cholera cases (66.2%) were reported in Abidjan (the economic capital and largest city) almost every year, with epidemics lasting an average of 15 weeks [10].

These diseases can be avoided by proper hygiene measures. Hygiene, in particular hand washing, plays an important role in the prevention of nosocomial infections and infectious diseases [11,12,13]. Washing hands at critical junctures is one of the most effective and cheapest public health measures for controlling the spread of infectious diseases [14,15,16]. According to the United States of America Centers for Disease Control and Prevention (US CDC), 80% of infectious diseases are transmitted by unclean hands touching contaminated surfaces. Therefore, washing hands at least five times a day is critically important for decreasing the frequency of acquiring colds, influenza, and other infections [17]. Handwashing reduces the number of people who become affected with diarrhea by 23–40%; reduces diarrheal illness in people with vulnerable immune systems by 58%; reduces respiratory illnesses, such as colds, in the general population by 16–21%; reduces absenteeism due to gastrointestinal illness in schoolchildren by 29–57% [17,18]. A follow-up study of the overall compliance with hand hygiene during routine care in a Geneva university hospital, where the development of a hydroalcoholic hand cleaning gel by Didier Pittet was trialed, contributed to a decrease in nosocomial infection prevalence from 16.9% in 1994 to 9.9% in 1998 (p = 0.04) [19].

For the prevention of EVD and COVID-19, in addition to other infectious diseases, handwashing appears effective and should constitute a standard precaution for disease prevention [17]. Therefore, there is an urgent need to engage in substantial promotional activity to change behaviors towards handwashing, especially in countries with a high burden of disease. Drastic measures, including maintaining high personal hygiene by frequent handwashing, have been widely recommended by the World Health Organization (WHO) and implemented by most countries to contain EVD and COVID-19 infections and to reduce the disease burden [20]. Nevertheless, despite these interventions, rates of effective prevention behaviors, such as handwashing with soap, in developing countries are still remarkably low [16]. The difficulties in maintaining proper hand hygiene compliances and handwashing techniques in the general population, and also in healthcare workers, can likely be attributed to a lack of facilities, training, information, and time, coupled with a high patient care load (in the case of healthcare workers) [21]. Hand hygiene is more efficient when based on demonstrations by qualified specialists using audio-visual aids [22]. However, in some cases, visual prompts do not contribute to an improvement in hand hygiene [13].

Some studies have focused on what happens to individuals, families, communities, or health systems after interventions when, for example, donor funding expires or government oversight wanes [23]. It has generally been noted that after interventions, when the threats have passed or are perceived to have passed, people return to their usual habits [14]. Certainly, most interventions have an impact on populations, but the duration and spatial temporal extent of that impact is often difficult to measure. Changes in behavior do not reach statistically significant levels or they are only measurable in the immediate post-intervention period and disappear after a few weeks or months [24]. According to Sidibe and Curtis (2002), safe hygiene promotion efforts may be more effective if they are built on the desire for cleanliness and reduced disease cost rather than relying on the fear of gastrointestinal infection [25]. It is, therefore, necessary to know how the Ebola and COVID-19 prevention measures have impacted dirty hand-disease mitigation in Côte d’Ivoire and to understand the sociocultural factors that may contribute to the maintenance of regular handwashing and disinfection in the absence of a crisis. As recommended by some studies, there is a need to explore the drivers of hand-hygiene practices among different age groups and to provide a snapshot of the current barriers and enabling factors to improve handwashing [26].

The purpose of the present study was thus two-fold. First, we sought to examine whether the prevalence of dirty hand diseases in Côte d’Ivoire had been impacted by the preventive measures against Ebola and COVID-19, considering the patients’ sex, age, and location (rural versus urban). Second, we sought to identify the sociocultural factors that may hinder or foster handwashing and disinfection in rural and urban communities.

2. Materials and Methods

2.1. Study Setting

Abidjan, the economic capital and largest city of Côte d’Ivoire, was selected because of the observation of recurrent cases of seasonal influenza, cholera, and typhoid fever, which are the main diseases caused by dirty hands. Abidjan was also the epicenter of COVID-19 infections in Côte d’Ivoire. Taabo is a small locality located in the Agneby-Tiassa region in south-central Côte d’Ivoire, about 150 km northwest of Abidjan and 60 km south of Yamoussoukro (the political capital of Côte d’Ivoire). The Taabo site was chosen because of its rural nature and the presence of the “Taabo Health and Demographic Surveillance System” agency [27], where several interventions on hygiene have been conducted. Neither site had experienced Ebola cases but had been exposed to prevention measures that were promoted during the crises in Liberia, Guinea, and Sierra Leone between 2014 and 2016.

2.2. Study Design

The study was conducted between December 2020 and September 2021. A retrospective study was conducted in the general hospitals of Taabo (south-central part of Côte d’Ivoire) and Marcory (Abidjan) to collect clinical data found within patients’ records from 2013 to 2020. The two general hospitals represented level 2 healthcare facilities within the Ivorian public health system. These hospitals were selected due to the capacity of their diagnostic laboratories to confirm the presence of dirty-hand diseases in collected samples.

Additionally, eight focus group discussions (FGDs) were conducted to identify the sociocultural factors that may hinder or enable handwashing and disinfection. Four FGDs were held in Taabo, including two in the town of Taabo and two in Ahondo, a village in the surrounding area located 14 km from the town of Taabo. The other four FGDs were conducted in Abidjan within the municipality of Adjamé, which was randomly selected from amongst the 13 municipalities of the Abidjan administrative district.

2.3. Study Population and Data Collection Procedure at General Hospitals of Taabo and Marcory

The population of the retrospective study in the hospitals included all patients who were at least 13 years old and who had entered either the general hospitals of Taabo or Marcory between 2013 and 2020 with the following symptoms: fever, cough, diarrhea, vomiting, and abdominal pain. These symptoms were chosen as they correspond to the symptoms of influenza, cholera, or typhoid fever. We decided to collect data on patients from 13 years old upwards, as the minimum age at which an individual is deemed capable of criminal responsibility under Ivorian law is 13 years old; thus, at this age, a child was considered capable of discerning and defining symptoms of diseases.

For the retrospective study, a purposive sampling methodology was used to target and focus only on patients meeting the inclusion criteria. Indeed, each individual seeking healthcare in one of those hospitals, with information recorded in the health registers, was eligible. Personal information of individuals, as recorded in the health registers, was compared with the inclusion criteria. Patients whose personal information met the inclusion criteria were selected and included in the study sample. Data from the registers were collected using tablets equipped with the “Open Data Kit” (ODK) application. Approval was obtained from the national ethical committee of Côte d’Ivoire (N°166-20/MSHP/CNESVS-kp). Access to the data of the health registers was facilitated by the issuance of an approval letter by the National Director General of Public Health, which was addressed to the leadership of the general hospitals of Taabo and Marcory.

2.4. Study Population and Data Collection Procedure for Focus Group Discussions (FGDs)

For focus group discussions (FGDs), the methodological assumption for the selection of participants was that compliance with preventive measures in non-pharmaceutical interventions, such as handwashing, during pandemics was determined by the living environment, age, and gender of the individual. The following age and gender categories were considered when selecting participants for the interviews in Taabo and Abidjan: adult males (from 35 years old); adult females (from 35 years old); young males (18–35 years); young females (18–35 years).

The FGDs were conducted in French by a social scientist acting as a moderator and assisted by an observer for notetaking and reporting. After seeking oral and collective informed consent from the participants, each focus group discussion lasted approximately 45 min and was recorded using a digital voice recorder. In Abidjan and Taabo, each FGD was composed of 6–10 participants selected from within the community. Discussions were structured around: (i) knowledge of COVID-19 and prevention measures; (ii) incentives and barriers around handwashing and disinfection; (iii) communication and accompanying measures for handwashing and disinfection sustainability.

2.5. Data Analysis

The data from the hospitals were extracted into a Microsoft Excel 2020 extension. Data were then imported into R software version 4.2.1 (R foundation team, 2022). The Chi-squared (χ²) test or the Fisher exact test were performed to compare dirty hands prevalence according to sex, age, and origin. Statistical significance was defined at a p-value < 0.05.

Each disease -representing outcome was analyzed alone using a generalized linear model based on logistics distribution. Variables included in the model were based on stepwise selection and AIC was used to select the best fitting model. Health outcomes were categorized into binary variables: typhoid fever (1 = affected, 0 = not affected) and influenza (1 = affected, 0 = not affected). In the logistic regression analyses, sex, age, period before Ebola, period during Ebola, period between Ebola and COVID-19, and period during COVID-19 were used as fixed variables. Two separate regression analyses were carried out for typhoid fever and influenza.

The recordings of the FGDs were systematically transcribed into Microsoft Word 2020. Transcripts were subsequently transferred to MAXQDA software for coding. A list of codes was developed based on the indicators of the various research objectives and complemented after a careful reading of all the transcripts. The coded segments were grouped together and synthesized into a few main categories during content analysis and interpretation.

This study utilized content analysis (CA) to assess the sociocultural factors that fostered or hindered handwashing and disinfection promotion strategies among populations. Content analysis could be viewed as an interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns. This analytic approach was particularly used for organizing ideas according to the convergence of meanings, establishing groupings of points of view on discussed topics, and drawing up a writing plan to interpret the results. This study adopted a conventional content analysis approach [28] that made it possible to gain direct information from the analyzed content without imposing preconceived categories or theoretical perspectives. The main categories identified during the CA analysis were conceptions of hand washing and hand hygiene; incentives for hand hygiene; barriers to handwashing and disinfection.

3. Results

3.1. Sociodemographic Characteristics of Patients

In Taabo, among the 3245 patients who visited the general hospital and who met the inclusion criteria from 2013 to 2020, there were 1847 females (56.88%) and 1398 males (43.08%). Patients ranged in age from 13 to 95 years, with an average age of 31 ± 14 years. Most patients were young (n = 1672, 51.53%), under 30 years of age, and were of Ivorian nationality (n = 2858, 88.07%) (

Table 1. Sociodemographic characteristics of patients at Taabo and Marcory general hospitals.

Patient Characteristics	Taabo Hospital	Marcory Hospital
	n (%)	n (%)
Distribution of patients by sex
Female	1847 (56.88)	5305 (65.06)
Male	1398 (43.08)	2849 (34.94)
Total	3245 (100)	8154 (100)
Distribution of patients by age
<20	747 (23.02)	1206 (14.79)
[20–29]	925 (28.51)	3230 (39.61)
[30–39]	744 (22.93)	2021 (24.79)
[40–49]	388 (11.96)	860 (10.55)
[50–59]	236 (7.27)	487 (5.97)
[60–69]	142 (4.38)	238 (2.92)
[70–79]	49 (1.51)	88 (1.08)
[80–89]	9 (0.28)	21 (0.26)
[90–95]	5 (0.15)	3 (0.04)
Total	3245 (100)	8154 (100)
Distribution of patients by origin
Côte d’Ivoire	2858 (88.07)	6708 (82.27)
Other African countries	385 (11.86)	1432 (17.56)
Europe	2 (0.06)	9 (0.11)
Asia	0 (0.00)	3 (0.04)
America	0 (0.00)	2 (0.02)
Total	3245 (100)	8154 (100)

).

At Marcory general hospital, among the 8154 eligible patients there were 5305 females (65.06%) and 2849 males (34.94%). Patients ranged in age from 13 to 95 years, with an average age of 31 ± 12 years. Most patients were young (n = 4436, 54.40%), under 30 years of age, and were of Ivorian nationality (n = 6708, 82.27%) (Table 1).

3.2. Prevalence of Dirty-Hand Diseases in Taabo and Marcory Hospitals

The prevalence of typhoid fever was 2.11% in Marcory and 3.70% in Taabo. There was no statistically significant difference in the prevalence of typhoid fever regarding sex, age, and origin in Taabo, whereas the prevalence of typhoid fever was linked to the sex of patients in Marcory; women were more affected than men, with a statistically significant difference (p < 0.005).

The prevalence of influenza was 0.41% in Marcory and 0.52% Taabo. There was no statistically significant difference in the prevalence of influenza regarding sex, age, and origin in Taabo, whereas the prevalence of influenza was linked to the age of patients in Marcory, with a statistically significant difference; patients aged between 70 and 79 were more affected (

Table 2. Prevalence of dirty hand diseases according to sex, age, and origin.

	Marcory (N = 8154)		Taabo (N = 3245)
	Influenza	Typhoid Fever	Influenza	Typhoid Fever
	34 (0.41)	172 (2.11)	17 (0.52)	120 (3.70)
Age
<20	2 (0.17)	25 (2.07)	5 (0.67)	28 (3.75)
[20–29]	5 (0.15)	79 (2.45)	5 (0.54)	36 (3.89)
[30–39]	11 (0.54)	40 (1.98)	4 (0.54)	37 (4.97)
[40–49]	3 (0.35)	20 (2.33)	2 (0.52)	9 (2.32)
[50–59]	7 (1.44)	7 (1.44)	1 (0.42)	5 (2.12)
[60–69]	4 (1.68)	1 (0.42)	0 (0)	4 (2.82)
[70–79]	2 (1.79)	0 (0)	0 (0)	1 (1.59)
p-value	<0.001 *	0.1759	0.999	0.2864
Sex
F	27 (0.51)	130 (2.45)	10 (0.54)	74 (4.01)
M	7 (0.25)	42 (1.47)	7 (0.5)	46 (3.29)
p-value	0.0853	0.004 *	1	0.328
Origin
Africa	1 (0.07)	39 (2.72)	1 (0.26)	19 (4.94)
America	0 (0)	0 (0)	0 (0)	0 (0)
Asia	0 (0)	0 (0)	0 (0)	0 (0)
Cote d’Ivoire	33 (0.49)	133 (1.98)	16 (0.56)	101 (3.53)
Europe	0 (0)	0 (0)	0 (0)	0 (0)
p-value	0.074	0.309	0.7106	0.251

* Statistical significance based on χ² or Fisher exact test.

).

3.3. Prevalence of Dirty Hand Diseases before Ebola, during Ebola, between Ebola and COVID-19, and during COVID-19

3.3.1. Before Ebola

At Marcory general hospital, from 2013 to 2014 (start of Ebola), the prevalence of influenza increased, whereas the prevalence of typhoid fever decreased. At the general hospital of Taabo, from 2013 to 2014 (start of Ebola), the prevalence of typhoid fever and influenza decreased.

3.3.2. During Ebola

From 2014 to 2015 (end of Ebola), the prevalence of typhoid fever and influenza increased at the Marcory general hospital. From 2014 to 2015 (end of Ebola), the prevalence of typhoid fever and influenza, increased at the general hospital of Taabo.

3.3.3. Between Ebola and COVID-19

At Marcory general hospital, from 2015 to 2016, the prevalence of typhoid fever increased. From 2016 to 2017, the prevalence of typhoid fever decreased. From 2017 to 2018, the prevalence of influenza increased, whereas the prevalence of typhoid fever decreased. From 2018 to 2019 (start of COVID-19), the prevalence of typhoid fever and influenza decreased.

At the general hospital of Taabo, from 2015 to 2016, the prevalence of typhoid fever and influenza decreased. From 2016 to 2017, the prevalence of typhoid fever and influenza decreased. From 2017 to 2018, the prevalence of typhoid fever and influenza continued to decrease, while it increased from 2018 to 2019 (start of COVID-19).

3.3.4. During COVID-19

At Marcory general hospital, from 2019 (start of COVID-19) to 2020, the prevalence of influenza decreased, whereas the prevalence of typhoid fever increased. At the general hospital of Taabo, from 2019 to 2020, the prevalence of influenza decreased, whereas the prevalence of typhoid fever increased (Figure 1).

3.4. Risk Factors Associated with Typhoid Fever and Influenza in Taabo and Marcory General Hospitals

Drastic measures, which were widely recommended by the World Health Organization (WHO) and were implemented by most countries to contain the Ebola virus disease and the COVID-19 infection, had no impact on the prevalence of typhoid fever, but these measures had a positive impact on influenza. Compared with women, men were more affected by typhoid fever (OR, 0.68 [95%CI, 0.53–0.88]) and influenza (OR, 0.87 [95%CI, 0.75–1]) (

Table 3. Prevalence of dirty hand diseases according to sex, age, and safe hygiene promotion during Ebola and COVID-19.

	Influenza		Typhoid Fever
	OR (95%CI)	p Value	OR (95%CI)	p Value
Period of outbreaks
During Ebola	2.34 (1.76–3.12)	<0.001 *	1.23 (0.49–3.09)	0.656
After Ebola	2.77 (2.11–3.65)	<0.001 *	1.5 (0.63–3.57)	0.362
During COVID-19	1.42 (0.99–2.03)	0.055 *	1.05 (0.4–2.76)	0.925
Sex
Male	0.87 (0.75–1)	0.047 *	0.68 (0.53–0.88)	0.003 *
Age
[20–29]	0.9 (0.74–1.1)	0.299	1.12 (0.8–1.56)	0.501
[30–39]	0.9 (0.73–1.11)	0.329	1.09 (0.77–1.56)	0.626
[40–49]	1.08 (0.84–1.38)	0.537	0.9 (0.57–1.42)	0.652
[50–59]	0.98 (0.72–1.33)	0.908	0.64 (0.34–1.2)	0.162
[60–69]	0.75 (0.49–1.15)	0.183	0.47 (0.19–1.19)	0.112
[70–79]	0.68 (0.36–1.28)	0.237	0.2 (0.03–1.47)	0.115

* Significant for p < 0.05. OR—odds ratio. References are female for sex, <20 years for age group, and before Ebola for period of outbreaks.

).

3.5. Sociocultural Factors Affecting Handwashing and Disinfection Promotion Strategies

Although hygiene measures such as handwashing with soap are effective interventions for sanitizing hands contaminated with pathogens, several sociocultural factors contribute to fostering or hindering compliance with hand hygiene promotion strategies. Improving handwashing behavior, stool disposal practices, and food hygiene in particular are socially constructed and vary according to perceptions and world views of populations. Hygiene behavior is commonly associated with socioeconomic factors, such as wealth, education, access to water, and modern lifestyle attitudes. For some people, for example, hygiene practices such as handwashing rituals are critical in the achievement of religious and other cultural objectives. Perceptions and representations of hygiene constructed by social and cultural factors as well as economic conditions affect positively or negatively the compliance of populations to handwashing and disinfection promotion measures and interventions.

3.5.1. Fostering Factors for Hand Hygiene According to Populations

Washing hands is an act of cleanliness that is observed by every human being. It is recognized that African cultures promote hand hygiene in daily life. For informants from Taabo and Abidjan, there are two major incentives related to hand washing: cleanliness and protection against diseases. Handwashing has cultural and symbolic underpinnings. It is associated with major daily events such as eating, relieving oneself, praying, etc. Washing hands is an important circumstantial event in the relation of the individual with him/herself, with their society, and with the environment. As one participant in a group discussion in Taabo opined:

“Cleanliness is embedded in our cultures. In our villages, when you wake up in the morning you take care of the environment—sweeping the compound—and your body—having a shower. Even though hand washing is related to some circumstances such as eating or praying, it was not difficult for us to comply with governmental recommendations since the Ebola outbreak because it is already a habit for us”.

(FGD with adult participants in Ahondo-Taabo)

Preserving themselves against diseases is another motive behind the adoption of hand washing by populations in Abidjan and Taabo. For them, when people are aware of health risks in their environment, they are more likely to respect prevention measures by washing their hands. According to some participants from Taabo:

“When there are awareness campaigns in the form of media hype as was the case at the beginning of the ongoing COVID-19 pandemic, people massively complied with handwashing. Contrary to Ebola few years before, the disease is present in the country and sometimes we have parents who have contracted it, so people were afraid. However, when the resonance of the recommendations decreased in media, there was a relaxation in the compliance with those measures”.

(FGD with young informants in Taabo)

For those informants, permanent communication on prevention measures against a disease seemed to be positively associated with compliance with the prescribed regulations. Awareness, capacity building, and education were critically important to maintaining compliance with handwashing measures at a high rate. Therefore, in addition to mainstream media, the local populations reported that they would like the involvement of traditional and administrative authorities and health personnel, as well as schoolteachers, in raising community awareness. That idea was discussed with people from the Taabo rural community, who recognized that:

“Recently, administrative authorities said during a meeting that even though we do not yet have Covid-19 cases in our community, we should take our precautions because with such a disease we never know when it will arrive. We should be ready by keeping our environment and our body clean. We have been sensitized to always keep our hands clean by washing with soap or using a hand sanitizer. We need someone familiar to us to raise our awareness every day because people are still skeptical about the existence of the disease and are reluctant to comply with prescribed measures”.

(FGD with adult participants in Taabo)

3.5.2. Barriers to Handwashing and Disinfection

The perceived social costs of hand sanitizer and difficulties in accessing safe water were cited by respondents as the main barriers. Financial reasons were listed as the main constraints for handwashing. Participants of group discussions claimed being unable to afford the cost of hand hygiene (water, soap, and hand sanitizer) during and after outbreaks of Ebola and COVID-19. They perceived the limited access to soap and water as hindering factors to good hygiene practices. Concerning water issues, even respondents from Abidjan claimed that they were not able to wash their hands properly because of the poor water supply by the national company in charge of water provision. For most of them:

“Washing hands is for us a very common practice. Everybody does it on a regular basis within a day. However, what happens is that, ironically, since the beginning of COVID-19, our taps have run out of water. In that case, how are we going to wash our hands? Can you imagine that we are in Abidjan [the economic capital of the country, located by the sea and in a well-watered hydrographic zone], but we lack simple water to wash our hands?”.

(FGD with adult men in Abidjan)

Apart from the lack of running water in households in rural and low-income urban areas, difficulties facing populations also included the high cost of water and soap, the absence of handwashing facilities in public spaces, and the absence of soap in public handwashing facilities when they did exist. Thus, barriers to hand hygiene behavior were not only related to the availability of water or the affordability of detergents, they also included the lack of, or the low availability of, handwashing facilities. Therefore, people from Taabo and Abidjan, whether they were from rural or urban contexts, were more likely to wash their hands at home. Furthermore, they were often unable to do so in public spaces due to poor coverage in sanitation and hand washing facilities.

This posed the problem of responsibility in the provision of basic social services to communities. During Ebola and COVID-19 outbreaks, handwashing devices (buckets equipped with a tap) were being provided to populations, especially in vulnerable communities, to supplement handwashing facilities when they existed. However, within the community, nobody bore the responsibility of supplying these “common goods” with water and/or soap, making the handwashing device dysfunctional. This was recognized by participants during a discussion in Taabo:

“we are facing a major constraint for handwashing. Handwashing devices have been deposited in public places in our neighbourhood. However, nobody supplies it with water and soap. When the bucket runs out of water, who is going to replace it? Who will accept to refill the bucket when it is empty and bear the cost of water? The municipality should take this responsibility to refill the buckets and provide soap because the cost of living is very high for us”.

(FGD with adult women in Taabo)

In the discussions, some informants argued that hand hygiene was easier to sustain with coercion and responsibility from (traditional, municipal, and governmental) authorities. For populations from Abidjan, hand hygiene and compliance with other governmental measures against outbreaks of infectious diseases such as Ebola and COVID-19 were more likely to be successful in public spaces such as supermarkets, banks, governmental buildings, and offices, etc. The success was because, in those spaces, the institutional leadership bore the costs related to the provision of hand sanitizer (or water with soap) and the enforcement of the regulations (security personnel at the entrance for monitoring). However, in other popular public spaces where the social cost of hand hygiene was too high, such as public transport, local markets, stadiums, etc., hand sanitizing was not respected. In that regard, the enforcement of preventive measures by governmental authorities and communication were critical to encourage good hygiene practices among the population in the time of pandemics. For a participant of the group discussions in Abidjan:

“when COVID-19 started, the government was very strict about hygiene measures. When we went to the market, we had to wash our hands before going back. The market was often closed to be sanitized. Now, the authorities barely talk about those measures as they used to do at the beginning of the pandemics. All the regulations are relaxed. If there is no more rigor, people will do whatever they like. This is the case in public transport. There used to be a limit to the number of seats in the public transportation. Now this rule is no longer respected. People are so close in the cars that when the apprenti [assistant to the drivers in informal minibuses] speaks when collecting transport fare, his saliva can land in your mouth. We are at high risk when there are not strong measures”.

(FGD with adult women in Abidjan)

Handwashing with soap in the community is essential to effectively prevent and control infections.

4. Discussion

The retrospective study conducted in the general hospitals of Taabo and Marcory revealed that the most common dirty-hand diseases were typhoid fever and influenza. From 2013 to 2020, a total of 172 cases of typhoid fever (with a male/female sex ratio of 0.32) and a total of 120 cases of typhoid fever (with a male/female sex ratio of 0.62) were reported at Marcory and Taabo, respectively. The number of cases reported in each rural and urban hospital in our study was lower than that reported in the survey conducted in Morocco on the epidemiology of typhoid fever from 2013 to 2016. Indeed, in that study, 322 cases were reported, with a male/female sex ratio of 0.9 [29]. Our results also differed from those reported in Benin, where 1027 cases were reported from 2015 to 2019 [30]. Our study showed that most of the typhoid fever cases were reported in the urban hospital of Marcory and that women were more affected than men, with a statistically significant difference. However, typhoid fever is still prevalent in rural areas and is attributable to the lack of safe drinking water supplies, poor hygiene, and contaminated food [31]. Our findings related to sex in the Marcory hospital were also in line with those of a study conducted in Islamabad (Pakistan), where the authors found that females were more often affected by typhoid fever than males [31].

Concerning influenza, the prevalence of this dirty hand disease in the Taabo (0.52%) and Marcory (0.41%) hospitals in our study was much lower than that reported in a study on the prevalence and management of lower respiratory diseases in public health facilities in the municipality of Yopougon (another municipality of Abidjan). In this study, in Yopougon, 4,150 patients were identified as suffering from lower respiratory disease, with an annual prevalence of 8.01%. Among the lower respiratory pathologies identified, acute bronchitis was predominant and was identified in 63.86% of cases [32].

Moreover, the study showed that, in both hospitals, the preventive measures mandated by the government during these two major health crises of international significance had no statistically significant impact on the prevalence of typhoid fever but had a positive impact on influenza. This result of the study regarding typhoid fever suggests inadequate handwashing, with the cost of soap and hand sanitizer being a possible explanation for inadequate handwashing [33].

Otherwise, in our study, participants of FGDs between 18 and 35 years and adults from 35 years old revealed that access to hand sanitizers and handwashing facilities with soap and water were the main incentives for hand hygiene, whereas the social costs of handwashing and the difficulties in accessing safe water were the main barriers to handwashing and disinfection. Our findings were different from those of a study conducted in 2021 on the influence of gender, age, and field of study in formal education on hand hygiene in young adults. Indeed, in this study, being a female aged between 22 and 25 years old and having studied in health sciences had a positive influence on correct hand hygiene. On the contrary, being a male aged between 18 and 21 or 26 and 29 years old and currently studying or having studied in the arts and humanities fields of study and, to a lesser extent, studying or having studied in the fields of engineering and architecture were identified as barriers to correct hand hygiene [34]. Our results also differed from those obtained in a study on the general quality of handwashing and hand-hygiene practices of the public of Hong Kong. In this study, authors showed that as age increased handwashing became more neglected. However, participants with higher educational levels had fewer missed areas of the hands when washing and they performed handwashing on a more regular basis [35]. A study, carried out in Bangladesh among 200 undergraduate students from four universities on hand hygiene knowledge and practice, indicated that the main reasons for skipping handwashing at home and in the university setting were participants’ beliefs that they “keep forgetting”, there was “no need”, and there was a poor water supply [36]. Another relevant study showed that internal factors such as knowledge and intentions; interpersonal factors such as social norms; environmental factors such as reminders, cues, accessibility, and cleanliness of handwashing facilities determined the level of hand hygiene practiced among young adults aged 18 to 25 and public health experts in Canada [26]. According to a study on the knowledge, attitudes, and practices regarding the COVID-19 outbreak in Côte d’Ivoire, beyond unfavorable socioeconomic conditions, the level of knowledge regarding COVID-19 and the trust in the government/health system were more likely to influence compliance with preventive measures such as self-reporting, physical distancing, the use of face masks, and, eventually, the acceptability of vaccines [33]. The findings of this previous study also indicated a positive association between heath interventions consisting of communication and awareness campaigns and compliance with prescribed measures against infectious disease outbreaks. This result was in line with the conclusions of a systematic review of studies on the sustainability of health interventions implemented in Sub-Saharan Africa [20]. For the authors of the review, community ownership and mobilization were recognized as crucial facilitators for intervention sustainability, both early on and after intervention implementation. The linkages between the sociocultural and community context in which the intervention occurred, the organizational factors in which it operated, and the timeframe of the implementation were critically important for the sustainability of the intervention [20]. Studies on the assessment of intervention impacts showed that the significant change in intentions observed immediately post-intervention had worn off after a few weeks or months [21]. This was found to be the case in Taabo and Abidjan, when the intensity of communication and awareness campaigns decreased.

The mode of data collection in hospitals (retrospective and making use of health registries) constituted a limitation to our study. Information biases were related to the incompleteness of the information in the consultation registers. In addition, data were collected after the first year of the COVID-19 pandemic, making the assessment of the impact of preventive measures enacted by the government on hand hygiene inconsistent due to the short length of time for which data were available post-implementation. An assessment a few years after the implementation of preventive measures against COVID-19 could produce more robust findings and allow for a more thorough comparison of pre- and post-intervention contexts. Another limitation was related to the fact that influenza was considered a dirty hand disease, although it can also be transmitted by aerosols in addition to dirty hands. Nevertheless, the large sample size obtained by our study provided good statistical power.

Despite these shortfalls, our study shed new light on the impact of Ebola and COVID-19 prevention measures on the dynamics of the prevalence of dirty hand diseases and also on the sociocultural factors that may hinder or foster handwashing and disinfection promotion strategies in Côte d’Ivoire.

5. Conclusions

Herein, we described one of the first studies conducted on the impact of Ebola and COVID-19 prevention measures on the evolution of the prevalence of dirty hand diseases in Côte d’Ivoire. The study showed that the prevalence of typhoid fever in both general hospitals had not been impacted by the preventive measures mandated by the government before Ebola, during Ebola, between Ebola and COVID-19, and during COVID-19. Nonetheless, our results have shown that these measures had a positive impact on influenza. Populations were aware of the importance of handwashing for public health but had difficulties adhering due to financial constraints, access to drinking water (especially in precarious environments), and the absence or scarcity of handwashing facilities. The provision of drinking water and basic hygiene and sanitation facilities, the regular promotion of sustainable hand washing and disinfection by the governmental local and national authorities, as well as permanent communication through mainstream and social media and community outreach, appeared as critical factors for encouraging good hygiene practices among the population during pandemics. The study highlighted the importance and need for further improvement in the existing hand-hygiene behavioral-change communication programs for addressing the gaps in knowledge, attitudes, and practices.