Factors associated with the practice of water, sanitation, and hygiene (WASH) among the Rohingya refugees in Bangladesh

The Rohingya people are now living in overcrowded refugee camps and makeshift settlements with low standards of water, sanitation, and hygiene (WASH). This study was conducted to examine WASH practices and associated risk factors among the Rohingya refugees in Bangladesh. The present study comprised 350 participants with data collected via a semi-structured questionnaire. Most respondents (84%) did not have good knowledge concerning WASH. Furthermore, 50.3% had unsafe WASH practices, 38.6% had fair WASH practices, and 11.1% had safe WASH practices. WASH practices were signi ﬁ cantly associated with age, education, marital status, and WASH knowledge. The implementation of an effective WASH awareness program is required along with improved water supply and sanitation to improve WASH practices among Rohingya refugees in Bangladesh.

Bazar district of Bangladesh, bringing the total number of Rohingya refugees residing in Bangladesh to approximately 910,000 (UNHCR ).
This mass migration has created extensive pressure on services existing in the refugee camps and makeshift settlements (Iacucci et al. ). Essential services, including food, water, health service access, and mostly shelter and sanitation, are insufficient in properly accommodating the needs of the refugees (Iacucci et al. ). The unsanitary living conditions accompanied by poor water, sanitation, and hygiene (WASH) practices have facilitated the emergence of many infectious diseases, i.e., diarrhea, cholera, chickenpox, and diphtheria. (Ahmed et al. ; Cousins ; Hsan Naher & Siddique ). Consequently, the present study was conducted to establish baseline information concerning WASH practices and investigate factors associated with WASH practices among Rohingya refugees.

Participants
The present study was descriptive, cross-sectional, and con- Multistage sampling techniques were used to collect data.
First, two refugee camps were selected using convenience sampling. Then, households were selected by using disproportionate stratified random sampling, and the sample was selected using purposive sampling.

Materials and data collection
Data were collected via face-to-face interviews using a threesection semi-structured questionnaire that was pretested among 10 refugees and developed by a team of three academic experts knowledgeable in the area. Section 1 comprised questions relating to socio-demographic variables (age, sex, religion, education, marital status, family size, duration of staying in Bangladesh, etc.). Section 2 comprised questions assessing WASH knowledge of refugees concerning water, sanitation, and hygiene, including the Predictably, most participants in the 'above secondary education' group had good WASH knowledge (61.5%). The study found no significant differences between males and females (χ 2 ¼ 2.802, p ¼ 0.246) concerning WASH practice knowledge (see Table 1).

Practice of water, sanitation, and hygiene (WASH)
Good WASH practices are especially important for promoting good health ( Joshi et  ). In addition, the study found significant gender differences in the sources used to access drinking water (χ 2 ¼ 9.452, p ¼ 0.024) ( Table 1).
Among the total participants, 56.3% reported that responsible household members always put covers on water containers during transportation and storage time, 2.9% did it sometimes, and 40.9% had never done so.
Hand hygiene is one of the most important practices to avoid getting sick and spreading germs to others. Washing with water alone removes pathogens, but is not as effective as using soap (Phillips et al. ). However, habits and cultural norms can be disrupted in the setting of internal displacement, thereby potentially changing practices such as handwashing (Phillips et al. ). In the present study, the self-reported frequency of handwashing was the highest in 'before eating' (94%). This was followed by handwashing after going to the toilet (92%), after touching dirty objects (84.9%), before preparing food (64%), and before feeding a child (63.4%). The study found significant gender differences with females being more likely to wash hands before feeding a child (χ 2 ¼ 31.291, p < 0.001) and preparing food ( In the present study, the majority of the participants (52.9%) reported using communal toilets (usually blocks of multiple toilets available to all individuals) as the main facility of defecation. This was followed by shared household

CONCLUSIONS AND RECOMMENDATIONS
The present study reported baseline information and associated risk factors concerning several WASH practices among Rohingya refugees in Bangladesh. Findings showed that the majority of participants had unsafe WASH practices. Findings showed that knowledge of WASH, age, education, and marital status were associated with engaging in WASH practices.
Based on these findings, a number of recommendations are suggested (i) an effective WASH awareness program for Rohingya refugees is required, (ii) any WASH awareness program needs to take into account that high numbers of refugees are illiterate and that programs based on written literature alone will only have limited success, (iii) awareness programs need to include educated WASH 'ambassadors' from within the refugee community, because this group is more knowledgeable about (and engages in more) WASH practices, and (iv) the refugee camps need an improved water supply and sanitation to help improve WASH practices.