A mixed-methods nutrition, water, sanitation and hygiene knowledge, attitudes, and practices survey of IDPs, returnees, and host community members in four counties of Jonglei state, South Sudan

Background: The humanitarian community in South Sudan estimates that 9.4 million people need humanitarian assistance in 2023. Prior data is unlikely to reflect the current health situation of Jonglei state given the influx of internally displaced persons (IDPs) and returnees. Methods: We conducted a cross-sectional, randomly sampled, mixed-methods, population-based household study during a 4-week period in June-July 2023 in ten bomas in four counties of Jonglei, South Sudan. Snowball sampled qualitative interviews were used for triangulation of quantitative data. The study was conducted to understand nutrition and water, sanitation, and hygiene knowledge, attitudes, and practices of IDPs, returnees and the host communities. Results: A total of 859 households consented to the study (586 females and 273 males) with a response rate of 96% among females and 94% among males. Forty-two percent of households identified three or more strategies to prevent starvation or malnutrition. Up to a fifth of households were unable to identify any strategies to prevent starvation or malnutrition with the host community having the highest rate (20.2%) when compared to IDPs (13.4%; p = 0.018) or returnees (10.4%; p = 0.006). Only 34% of respondents could name three warning signs for when a child with diarrhea should be seen by a skilled provider. Only 26% of females exclusively breastfeed. Higher odds of breastfeeding included IDPs (aOR 1.11; 95% CI 1.01 to 1.03; p = 0.038), those educated on breastfeeding (aOR 1.18; 95% CI 1.03 to 1.35; p = 0.015) and those with positive nutrition attitudes (aOR 1.32; 95% CI 1.09 to 1.59; p = 005). Estimated household water usage ranged from 7.9 to 10.1 L/person/day. Based on qualitative triangulation, both nutrition and WASH traditional beliefs hinder adequate nutrition and create barriers to improvements in WASH. Conclusion: Evidence based nutrition interventions should be the priority and include, at a minimum, micronutrient and vitamin supplementation, food fortification and adequate supplemental food for reproductive age females. Immediate and exclusive breastfeeding messaging should be a priority. Improved flood resistant sources for clean water, clean covered water storage container distribution, improved sanitation, oral rehydration solution (ORS) and zinc distribution and education are necessary to decrease diarrheal rates.