Anal Cleansing Practices, Perceptions and Barriers Among Refugees in Imvepi Refugee Settlement, Arua District, North West Uganda

Abstract Introduction and Background: Anal cleansing practices, perceptions and barriers in Imvepi refugee settlement presents a challenging hygiene problem where the adequacy of available anal cleansing materials in ensuring finger hygiene after cleansing is still unknown. This problem results into continued faecal-oral contamination routes after defaecation. Water, Sanitation and hygiene policies provide guidelines of appropriate WASH practices however in the area of anal cleansing these guidelines are not specific and only give generalised expectations. Therefore, the objectives of this study was to determine the anal cleansing practices, perceptions and barriers in Imvepi refugee settlement. Methods: This was a cross-sectional study involving the use of both quantitative and qualitative data collection methods. A total of 407 refugee respondents and key informants participated in this research. Respondents to the structured questionnaires were selected using two stage sampling with simple random sampling at each stage (333 respondents), Focus group discussions (64 respondents) and key informant interviews were held (10 respondents). Multivariate and Bivariate quantitative data analysis was carried out on anal cleansing practices using STATA version 14 while manual qualitative data analysis was carried out using thematic analysis on anal cleansing perceptions and barriers to the use of anal cleansing materials. Results: The anal cleansing materials commonly used in the refugee settlement are the traditional anal cleansing materials with a prevalence of 74% compared to 26% for the modern anal cleansing materials. Refugees aged between 15-19 years were significantly more likely to use traditional anal cleansing materials compared to those aged 40-44 years; APR: 1.325 95% CI[0.990-1.1772]. Refugee religion of Moslems was significantly more likely to use traditional cleansing material APR: 1.220 95% CI [1.056-1.409]. Refugees with primary and secondary education as the highest level of education were significantly less likely to use traditional cleansing materials APR; 0.704 95% CI [0.552-0.897].Adults in the refugee settlement were less likely to suffer diarrhoeal diseases compared to children APR; 0.766 95% CI [0.683-0.859]. Refugees that had not suffered diarrheal disease were less likely to have used traditional anal cleansing materials APR; 0.882 95% CI [0.779-0.998]. The major refugee perceptions on anal cleansing were that anal cleansing was of great importance for general health and social wellbeing, while poverty was seen as the major barrier to the use of modern anal cleansing materials. Conclusion and recommendations: Traditional anal cleansing materials were the most commonly used cleansing materials. From these research findings we can conclude that the prevalent use of traditional anal cleansing materials contributes to the high diarrheal infections among refugees in Imvepi refugee settlement North Western Uganda.The perceptions held on anal cleansing were that it was an important practice after defaecation to avoid the adverse effects of community rejection because of poor body odour however; the influencing factors were more associated with the environmental context in which they lived. The barriers to the use of modern cleaning materials were majorly on financial capability to purchase these modern anal cleansing materials as they were available in the refugee market places.