Maintaining Hand Hygiene in the Informal Settlements: Reflections on Compliance for Covid-19 Preventative Measures

Abstract

South Africa experiences challenges with informal settlements that have inadequate water supplies and sanitation measures, thus affecting people’s health status. As countries globally aim to attain Sustainable Development Goals 3 and 6, it is necessary to recognise how human well-being is significantly dependent on safe drinking water, sanitation and hygiene. Poor sanitation and an inadequate water supply to areas where people live lead to poor hygiene that may cause illnesses like diarrhoea. In this chapter, we reflect on the challenges that we faced during the Covid-19 pandemic and the effects on the practice of good hygiene. We used information from grey literature such as newspapers, reports from districts and radio interviews to extract stories from community members who experienced constraints in maintaining hygienic conditions during Covid-19. Results revealed that constraints, such as being confined in a shack, a lack of running water and poor sanitation affected community members’ compliance to Covid-19 preventive measures.

1. Introduction

The Covid-19 pandemic reached South African shores in 2020. The country was placed in a state of disaster management. Control and preventive measures were put in place to control the spread of Covid-19. Movements were restricted, resulting in the total lockdown of the country which was later managed through stages. The communities were made aware that the Covid-19 infection was spread by inhalation of infected droplets and contact with infected surfaces [1]. Different methods, such as social distancing, handwashing, use of sanitisers to maintain aseptic techniques to prevent the spread of the infection were introduced. The centres for disease control and prevention recommended and emphasised handwashing with soap and water for 20 seconds, repeatedly throughout the day. Other methods, such as the use of alcohol-based hand sanitisers, were also recommended [2]. Hand hygiene has always been a method that has been used in hospitals and clinics to prevent infection. However, COVID-19 put the practice into the spotlight for hand washing to be practiced by each and every member of society. This practice became a challenge, especially for people who are staying in informal settlements where issues such as social distancing and availability of running water remains a challenge.

In 2018/2019 the World Health Organisation (WHO) led an initiative to collect data on how governments and external support agencies (ESAs) worldwide are supporting hygiene [3]. Data was collected by the UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) [4]. The results of this initiative revealed that countries worldwide have put national policies and plans in place for hygiene; however, there is a lack of infrastructure to supply water and proper sanitation in certain areas [4]. Also, the sustainable development goal number 6 reads “ensure availability and sustainable management of water and sanitation for all by 2030” [5]. Despite that, water remains a scarce commodity in sub-Saharan Africa. Nearly 300 million people live in a water-stressed environment. In some countries, such as Kenya, people had to queue to get water, making it difficult for them to use the rationed water to wash hands frequently under running water, as expected, instead of bathing and cooking [6].

In South Africa, the issue of water remains a challenge caused by “insufficient water infrastructure maintenance and investments, inequities in access to water and sanitation, deteriorating water quality, and a lack of skilled water engineers and scientists”. The Covid 19 pandemic and the prescribed preventive measures showed the inequities in water supply and sanitation. The Department of Water and Sanitation provided approximately 41,000 water tanks to assist people living in informal settlements and rural communities to assist with running water during the Covid-19 era [7]. However, this practice is not sustainable when the country is no longer reporting high incidences of Covid-19.

The practice of handwashing with soap and water seems an easy and simple thing to do in countries that have running water. However, in developing countries, such as South Africa, where water is a scarce commodity, the practice is viewed as a luxury that is often impossible to attain. Water scarcity is a big challenge in the fight of the spread of Covid-19, especially for those people staying in the informal settlements. Water scarcity causes unhygienic conditions and poor sanitation that affects vulnerable people, like children, and encourages diseases, such as diarrhoea, cholera, malaria, and in this case, the spread of Covid-19 [8]. Health care professionals working in informal settlements are also unable to comply with the maintenance of aseptic techniques to curb the spread of infections. This issue of water scarcity does not align with the sustainable development goal number 3 that reads “Ensure healthy lives and promote wellbeing for all at all ages”.

South Africa is one of the countries that became an epicentre for Covid-19. Maintaining a clean and healthy environment in a place where people live in overcrowded conditions, the lack of water and basic sanitation is a challenge to the control of infection. Most of the poor people in South Africa live in informal settlements, such as squatter camps, rondavels and shacks. People living in informal settlements get water from outside taps and the toilets are outside their houses and they are communal which made it more difficult for them to comply with the preventive measures that were in place to promote hand hygiene and the spread of the Covid-19 virus [8]. Developed countries, such as Australia, suspended water shut-offs and closure for water access for those who were in debt to ensure water access [9]. Other developing countries, such as Ghana, spent money on water tanks to provide water to their communities during Covid-19 to make water available for hand washing to prevent the spread of the virus [9].

The importance of ensuring access to safe Water, Sanitation and Hygiene (WASH) was viewed as a priority to prevent the spread of Covid-19 infection. In this chapter, we reflect on the challenges experienced by people living in informal settlements regarding compliance to Covid 19 preventive measures in South Africa.

2. Research design and methods

An integrated literature review was used to obtain information regarding this topic. The keywords used were Covid-19, informal settlement, preventative measures, hand sanitizers, water scarcity, Wash. The websites used were EbscoHost, google scholar, Pubmed and CINAHL. We accessed articles from 2019 to 2022. We found 83 papers that we have read for selection of this book chapter. The majority of papers (66) were excluded as they were not relevant and 16 papers were found relevant to answer our research review question. Eleven papers were from the studies that conducted and published in data the selected data bases. Five papers were selected from grey literature, such as reports from Non-governmental organisation, newspapers, reports from districts and radio interviews, to extract stories from community members who experienced constraints to maintaining hygienic conditions during Covid-19. Thematic analysis was used to analyse the results for this book chapter.

3. Results and discussion

The findings that emanated from the literature reviewed regarding the constraints that affected community members’ compliance to Covid-19 preventive measures were grouped into two themes. The first theme was insufficient infrastructure, and the sub-themes were overcrowding in informal settlements, lack of running water and poor sanitation. The second theme was poverty as a barrier to hand hygiene during Covid-19 and the sub-themes were affordability of purchasing hand sanitisers and risk factors to illness due to the use of home-made and fake hand sanitisers.

3.1 Overcrowding

Proper housing has always been a challenge in South Africa. This has culminated in the proliferation of informal settlements which are mostly seen in urban areas of South Africa. Those living in inhospitable housing conditions like shacks, were reported to have found the Covid-19 lockdown regulations unbearable. The regulation of social distancing was difficult and impossible to adhere to as those living in crowded households (six people and more), were reported not to have been able to self-isolate where necessary, as they could not keep the necessary distance from one another. The possibility of contracting the Covid-19 infection in such conditions was high.

“As you can see, we live in a dense community and there is little we can do. Many of us live in small shacks in families of 10 to 15, so there is no way we can adhere to the social distance that the government speaks of” [10].

This assertion of poor housing and poverty in general, are considered to have exposed the vulnerable to the worst effects of the Covid-19 pandemic, compared to those who are relatively well-off [11]. Ironically, the inability of the shack-dwellers to comply with the health and safety guidelines or the Covid-19 lockdown restrictions were regarded by many as an unwillingness to conform [11]. Furthermore, the literature review indicated that most shacks in South Africa are built of boards and corrugated iron sheets, less than one meter apart and poorly ventilated due to small windows [12]. Therefore, people living in shacks often do not have a room to relax in but only one room to sleep, which aggravates the spread of infectious diseases.

3.2 Lack of running water

Lack of running water was reported as one of the constraints that contributed to the failure of community members of informal settlements to comply to hand hygiene as a preventive measure to Covid-19. This was supported by the Asivikelane community group in South Africa who reported that in February 2021 “water supply in informal settlements have deteriorated all over the country” [13]. There was a contract for filling water tanks to enable people living in informal settlements to have water. Lack of an adequate water supply to the informal settlements in South Africa, forced people to wake up early to stand in long queues waiting for the delivery of water by tankers. Similarly, De Groot and Lemanski reported that people from informal settlements were saying that.

“Every morning you’ve got to stand up early so that you could fill up your water bottles/buckets because you only get a certain amount of water per day” [14].

In those circumstances, issues of prioritising hand hygiene were compromised. In those queues, the issue of social distancing was not possible. Socio-Economic Rights Institute of South Africa (SERI) reported that access to water in informal settlements is generally limited to communal water sources [15]. A lack of adequate water supply has been a problem even before Covid-19. This was reported in 2011 when it was shown that about 12% of the 1,068,572 households in the City of Cape Town relied on a communal stand for access to tap water [15]. The number provided of standpipes were fewer than people’s need for water. For example, in the Marikana informal settlement, the City of Cape Town has provided 50 communal standpipes to provide water to at least 60,000 residents [15]. Some of the informal settlements used bath water that remained after bathing to wash their hands. In those situations, touching surfaces in their dwellings without washing their hands and further touching their eyes and mouth often resulted in the transmission of infection. Although they wanted to comply circumstances beyond their control became a challenge which was reported as follows:

“How can they tell us to was our hands when we do not have the facilities or the resources to do so? Some informal settlements do not have access to water. And too many are struggling with slow water pressure and not enough working pipes” [16].

Homeless people were also affected by the lack of adhering to hand hygiene and maintaining aseptic techniques despite being moved to tents for shelter during the era of Covid-19. According to Hara, Ncube and Sibanda, a homeless community that was moved to a temporary tented shelter in Cape Town, South Africa, expressed the lack of water as the major challenge [17]. One resident explained that while they were grateful for the tents, they still did not have access to water for hygienic purposes. In those communities, health care workers who were allocated to work with communities who were homeless and those living in informal settlements, were also affected as they could not practice hand hygiene and aseptic techniques because of lack of water. This is illustrated by the following quotations:

“The message from our government has been clear: ‘Wash your hands!’ But those of us living in informal settlements ask ourselves: ‘With what?” [16].

3.3 Poor sanitation

Poor sanitation also came up as one of the constraints due to unavailability of proper toilet facilities and to poor disposal of wastes. Many families in informal settlements are allocated to use one toilet which may not be suitable for the number of people utilising such toilet. In such cases, it sometimes becomes difficult to wait in a queue. People resort to using other methods such as buckets, plastic bags and porta-potties. These practices further exacerbated the poor waste disposal practices and the inability to wash hands after relieving themselves as water is often not available thus exposing them to the spread of the Covid-19 infection.

“we have a challenge – scarcity of water, and that makes it difficult for us to fight the disease. Many in informal settlements have to share a single communal tap” [10].

Furthermore, the use of open fields in which to relieve themselves was found to be causing pollution of the environment. Muanda, Goldin and Haldenwang revealed that informal settlement dwellers use these practices due to poor sanitation that exist in their surroundings, making if difficult for them to wash hands as required, because of lack of water availability [18]. The residents in Khayelitsha protested to the government saying that they cannot practice handwashing because of inadequate water supply as evidenced by the following statement: “‘Wash your hands!’ But those of us living in informal settlements ask ourselves: ‘With what?’” [16].

“Our areas are not regularly cleaned. Even our communal toilets have not been cleaned in over three months, and that could also lead to health issues” [16].

4. Poverty as barrier to hand hygiene during Covid-19

The second theme of this book chapter is poverty as a barrier to hand hygiene during Covid-19 and the sub-themes are affordability of hand sanitisers and the risk factors to illness due to home-made and fake sanitisers.

4.1 Affordability of hand sanitisers

Poverty was found to be a far more important barrier to lockdown regulations and compliance to Covid-19 preventive measures as many people living in informal settlements or shacks were not formally employed [12]. According to Nyashanu, Simbanegavi and Gibson, people living in shacks or informal settlements depend on the informal sector to support their families [19]. Those people who were selling on the streets could not continue selling their vegetables, fruits, fat cakes and braiding hair to generate an income. In addition, people were expected to buy hand sanitisers as another method to maintain hand hygiene as part of Covid-19 preventative measures.

Supply issues and the high cost of commercially produced sanitisers severely limit the use of Alcohol Based Hand Rubs (ABHRs) in developing countries [20, 21]. This was also the case in South Africa because most people residing in informal settlements could not afford to buy hand sanitisers. The government had to step in and support people living in informal settlements by giving them the hand sanitisers. The KwaZuluNatal (KZN) Provincial Executive Council directed the Human Settlements Department to launch an intensive sanitisation programme in informal settlements to assist them with hand sanitizers [10]. The sanitisation programme was implemented in all 729 informal settlements in the province’s 10 district municipalities and eThekwini Metro in April 2020 where bars of soap and hand sanitisers were distributed to households [10].

However, people living in informal settlements in Cape Town felt that the South African Government did not pay much attention to their needs when it comes to maintaining hand hygiene practices during Covid-19. In support of this, more than 80% of residents in Cape Town’s informal settlements said they had not received soap or hand sanitiser from the government [22]. One of the residents in informal settlements in South Africa said:

“Where are we supposed to get money for sanitisers when we don’t work?” [16].

“That is for rich people who can afford to buy soap all the time. Hand sanitiser is but a pipe dream. With little to no funds to secure basic necessities, hand sanitiser and extra soap are luxuries” [10].

“How are we supposed to get money for sanitiser when we don’t work?” We need money to buy bread for the children who are now staying at home for longer periods [23].”

Most of the residents in informal settlements rely on social grants. One of the residents in informal settlements raised this issue in a form of question and said:

“They barely meet our daily needs; why can’t the government go around to communities like ours and at the very least provide us with gloves, masks, and sanitisers during this period? [23].”

As much as the government tried to provide for sanitisers to reach everyone in need, the issue of inequality played a big role as the municipalities did not have enough money and equal resources for distribution.

4.2 Risk factors to illness due to the use of home-made and fake hand sanitisers

South Africans were not exempt from the use of fake hand sanitisers. The demand for hand sanitisers was high during the Covid-19 era, therefore some companies ended up making fake sanitisers [24]. The use of substandard and fake hand sanitisers was found to be dangerous to uninformed consumers because they cause skin irritant health related problems [24]. Also, Perera reported that knowledge on the use the use of fake hand sanitisers could pose a greater risk among residents in informal settlements in South Africa. There is a need for creating health awareness regarding the use of fake hand sanitisers for people in informal settlement [25].

Some of the measures that were used by people were home-made hand sanitisers. For example, In South Africa, people would say:

“We combine household disinfectant cleaning solutions such as Jik, Sunlight dishwashing solution, and/or Domestos to use as hand sanitisers and disinfectant for the prevention of Covid-19.”

In support of this, people in developed countries were also using home-made disinfectant for prevention of Covid-19 [26]. However, it has been reported that the ‘misuse’ of home-based hand sanitisers resulted in poisoning which was typically centred on chemicals used for cleaning at home in the era of Covid-19 [27].

5. Conclusion

The living conditions of people in informal settlements made it difficult for them to adhere to Covid-19 regulations in South Africa. Overcrowding was one of the challenges that was experienced by people living in informal settlements because as there was no enough space to maintain social distancing, self-isolation and quarantine when the need arose. This was exacerbated by the lack of access to running water for people to practice hand hygiene, as required. Lack of running water resulted in poor sanitation as people could not flush their toilets and wash to maintain hand hygiene. The majority of people in informal settlements were working in firms that closed and some of them had informal businesses which could not run as usual due to lockdown regulations. Some people decided to make their own home-based sanitizers, while on the other hand companies produced fake hand sanitisers which had a negative impact on their integumentary system resulting to skin rashes and cracks and predisposing them to poisoning. WASH is an important strategy to promote hygiene and to prevent the spread of infectious disease. The communities must be taught about hand washing as a basic course that is taught from the schools in order to attain goal 3 and 6. The South African government must made efforts to provide housing, better access to water and improve sanitation.