For example, recent studies havesuggested that handwashing reducesrates of diarrhoeal infection by 35 to48 per cent. The safe disposal of faecesin the school environment can reducediarrhoea by 44 per cent. Other aspectsof hygiene behaviour associated withreduced rates of intestinal infectionsinclude: protecting water from faecalcontamination at the source, in transit,and in the home; and protecting foodfrom faecal contamination during han-dling, preparation, and storage.

Studying hygiene behaviour - whereare we now?by Astier Almedom and Valerie CurtisWater and sanitation programmes aim to improvepeople's health, mainly by reducing the rates ofintestinal infections such as diarrhoea andworms. Long-term benefits will only come about,however, if people change some of their water-use and hygiene-related habits. In recent years,this realization has stimulated a resurgence ofinterest in the study of hygiene behaviour: whatis emerging?

Table 1. A guide to the relevant features and activities of the main hygiene-behaviourclusters.

Improving health?Evidence is growing of the key rolethat hygiene plays in children's health.

particular, on their behaviour, shouldmake such interventions more effective.At the London School of Hygiene andTropical Medicine (LSHTM) we arecurrently investigating this hypothesisin both the Environmental Health Pro-gramme (EHP) and the Maternal andChild Epidemiology Unit (MCEU).

DESPITE MAJOR INVESTMENTS- of money, time, and effort - incontrol programmes, over three millionchildren still die of intestinal infectionsin developing countries each year; athird of the world's population is stillinfected with parasitic worms.I,2 Ourfailure to defeat these diseases suggeststhat it is time to re-examine ourstandard approaches. It is increasinglyclear that our main control strategies,the development of sanitary infrastruc-ture, education about health and hy-giene, and the promotion of oralrehydration therapy, have limits. Fo-cusing on people's hygiene-relatedbehaviour may offer a key to increas-ing their effectiveness.

Improvements to water and sanita-tion infrastructure are excellent meth-ods for controlling intestinal infectionsin the long term, but only if they areused as intended; they need to belocally needed, acceptable, and afford-able. Similarly, health- and hygiene-education efforts are effective only ifthey are designed on the basis of soundsocio-cultural knowledge of the targetpopulation. Oral rehydration is effec-tive only in dealing with some of thelife-threatening symptoms of di-arrhoeal disease and no more. Theefficacy of oral rehydration dependson the mother's ability to prepare thesolution correctly, using clean utensilsand the right proportions of ingredi-ents, including clean water.

Lessons are being learned from theexperience of projects which havefailed to achieve their objectives be-cause of the planners' ignorance, ortheir lack of will - or their refusal -to learn; or because they have notactively involved their target popula-tions in design and planning. Focusingon the people who are the targets ofthese projects; on their social, eco-nomic, and cultural realities and, in

2

Clusters of hygienebehaviour

SanitationExcreta disposal(Cluster A)

WaterSources and uses(Clusters B and C)

FoodFood hygiene(Cluster D)

EnvironmentDomestic andenvironmental hygiene(Cluster E)

TargetingThe table below lists every aspect of aperson's behaviour - associated withsanitation, water, food, and the envi-ronment - which may pose a risk tohealth. Precisely which activities causethe greatest problem vary from oneplace and culture to another, althoughcertain habits are worth targeting forchange wherever they occur.

Following the international work-shop on the measurement of hygiene

Relevant features, behaviour, and activities

• Location of defecation sites• Latrine maintenance (structure and cleanliness)• Disposal of children's faeces• Handwashing at 'critical' times (after cleaning children's

bottoms; after handling children's faeces; after defecation)• Use of cleansing materials• Protection of water source(s)• Siting of latrines in relation to water source(s)• Maintenance of water source(s)• Water use at the source(s)• Other activities at water source(s)• Water-collection methods and utensils• Water treatment at the source• Methods of transporting water• Water handling in the home• Water storage and treatment in the home• Water use (and reuse) in the home• Handwashing at 'critical' times (before or after certain. activities, including religious rituals)

• Washing children's faces• Bathing (children and adults)• Washing clothes• Food handling/preparation• Utensils used for cooking, serving food, feeding young

children, and for storing leftover food• Handwashing at 'critical' times (before handling food,

eating, feeding young children)• Reheating of stored food before serving• Washing utensils and use of a dish rack• Sweeping of floors and compounds• Household-refuse disposal• Cleanliness of footpaths and roads• Management of domestic animals (cattle, dogs, pigs, and

chickens)

WATERLINES VOL.13 NO.3 JANUARY 1995

Recent studies show that handwashing at 'critical' times should be promoted globally.

behaviour· convened by the Environ-mental Health Programme in April1991, the World Health Organizationheld an informal consultation, with theaim of narrowing down the list.

WHO concluded that the followingsets of hygiene b~haviour are mostrelevant to the control of diarrhoealdisease and should be investigatedsystematically:o Safer disposal of human excreta,

particularly the faeces of youngchildren and babies, and peoplewith diarrhoea;

o handwashing, after defecation, afterhandling babies' faeces, beforefeeding and eating, and beforepreparing food;

o maintaining drinking-water freefrom faecal contamination, in thehome and at the source.3Researchers from the LSTHM have

carried out studies in West and EastAfrica, focusing on the disposal ofinfants and children's stools, and onhandwashing after contact with faecalmaterial. A study of hygiene behaviourin the Burkinabe town of Bobo-Dioulasso showed that the failure todispose of children's faeces in latrinesis associated with increased rates ofdiarrhoea.

The methods included a question-naire-based case-control study, struc-tured observations carried out in thecourtyards of the mothers included inthe sample, focus-group discussions(people from similar backgrounds orexperiences gathering to discuss aspecific topic of interest to the re-searcher) with women from differentbackgrounds, and a communicationsstudy. Plans are under way toimplement and evaluate a com-munications intervention targeted onsafe stool-disposal, and on usingsoap to wash hands after cleaningchildren's bottoms. The Bobo-Diou-lasso project has made importantmethodological contributions to thestudy of hygiene behaviour. Signifi-cant among these has been thesystematic appraisal of data obtainedby questionnaires, compared to thatobtained by structured observations.The results suggested that informationgathered by observation is, on thewhole, more reliable than that gatheredby questionnaire.4

Field trialsIn 1993, the EHP embarked on thetask of making the available anthro-pological and related methods and

tools for assessing hygiene behaviouraccessible to field workers (non-re-searchers) in healthfhygiene education,and water supply and sanitation pro-jects. This involved a series of fieldcollaborations with fieldworkers inKenya, Tanzania, and Ethiopia, withthe aim of identifying the mostrelevant hygiene behaviour andactivities to be assessed; and to field-test the available methods and tools forassessing them.

Interestingly, the findings of thesefield-trials suggest that the disposal ofchildren's stools, and handwashing atcritical times, are worth assessingsystematically. These results reflect thefindings of the Bobo Dioulasso study,although the health risk posed bydisposing of children's faeces by dig-ging and burying may be minimal inrural western Kenya and parts ofTanzania, when compared with urbanBurkina Faso where latrines are essen-tial. In both rural and urban settings inKenya, Tanzania, and Ethiopia, hand-washing with soap or alternatives suchas ash - after handling children'sstools, and cleansing infants and youngchildren - was found to be worthpromoting through participatory ap-proaches.5•6

WATERLINES VOL. 13 NO.3 JANUARY 1995 3

adopting participatory methods whichpromote a good rapport with thegroups under study, both individuallyand collectively - poverty continuesto limit people's capacity to put theirknowledge into practice.

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Behaviour change will only come ahout when people are cOnl'inced that theyshould practise what 'experts' preach.

tinue to become easier to investigateand understand, enquiries into sanita-tion-related behaviour remain difficult.Although common obstacles in observ-ing what 'people take great pains toconceal',? may be overcome by usingmore sensitive approaches - and by

Hygiene evaluations can be done atdifferent points during a programmecycle, depending on the purpose towhich they are put. For example,assessments of hygiene behaviourand activities are done early in aproject cycle for the purposes ofbaseline data gathering. They arealso done for the purposes of monitor-ing, for example, the effectiveness ofhealth-education interventions in themiddle of a project cycle; or at the endof a project cycle for the purposes ofproject appraisal.

Where are we now?As we go into 1995, much still remainsto be learned about hygiene behaviour,both in general, and specific settings.The four articles which follow concen-trate on some of the gaps in ourknowledge: how to identify behaviourwhich is a problem, how to understandand evaluate it, and how to interveneusing communications approaches.Further work is needed to widely field-test methods of measuring, assessing,and explaining hygiene behaviour;otherwise, behaviour change cannotbe promoted effectively.

While water-related practices con-

Environmental health adviserTibet: £15,262SCF has been supporting a programme of rural water supply and sanitationimprovements and health education in the Lhasa Municipality since 1991. Now anEnvironmental Health Adviser is required to work with the Regional Water ResourcesBureau (RWRBl and expond this programme beyond the Lhasa Municipality.

The programme aims to strengthen the ability of the RWRBto respond to the environ-mental health needs of the rural Tibetan population. This will be carried out bydemonstrating and promoting appropriate technologies and developmentalmethodologies for water supply improvements, and for integrating the promotion oflatrine-building and improved hygiene behaviour into a water-supply programme.The programme will have a strong focus on community participation, and will havea child·focused approach.

You will have considerable experience of advising or managing integrated environ-mental health programmes in developing countries, preferably within the structureof government deportments; an appropriate qualification; experience of promotingparticipatory approaches in community development; good diplomatic skills andhigh levelsof tact and potience; and preferably, spoken Tibetan or Mandarin Chineseand experience of working with a centrally planned governmental structure.

The post has accompanied status and is offered on a 25 month contract, with asalary of £15,262 which should be tax free. You can also expect a generous benefitspackage including accommodation, Rights, and other living expenses.

If you are interested and available, please send or fox your CV with a leffer in supportof your application toMichelle Dowling,Overseas Personnel,SCF, 17 Grove Lane,London SES 8RD.Fax: +44 171 7937610.Closing date: 17 March 1995.

SCF aims to be an equal opportunities employer.

Bridging the gapPerhaps the biggest problem thatremains to be solved is the gap betweenwhat is known - and what is beinglearned - and what is being done inpractice, in the field. Fieldworkersknow a great deal about operationalmatters. Likewise, applied researchersare very knowledgeable about theoreti-cal advances and lessons learned at aglobal level. It is high time that thetwo groups worked together, andmade it possible for target populationsto participate meaningfully in projectactivities aimed at behaviour change.The targets of behaviour changehave to be convinced that it is worththeir while to practise improvedhygiene. Only then will the intendedhealth benefits be achieved throughimprovements in water supply andsanitation.

This issue of Waterlines aims tocontribute towards bridging theresearcher/practitioner gap by lookingat the experience of four projectsstudying food hygiene, excretadisposal, water-related hygiene, andwater quality and uses:

o Food hygiene Sandra Saenz deTejada and Floridalma Cano reporton a qualitative study in Guatemalawhich formed the basis of aneducational intervention on wean-ing-food hygiene. They look spe-

4 WATERLINES VOL. 13 NO.3 JANUARY 1995

ing Hygiene Behal'iour, Sage, New Delhi,1994.

8. Jamieson, D.T. and Mosley, W.H. (eds.),'Evolving health-sector priorities in develop-ing countries, World Bank, Washington DC.1991.

Astier Almedom is a medical anthropologist ill

the Departmellf of Epidemiology and PopulationSciences' Tropical Health Epidemiology unit, atthe London School of Hygiene and TropicalMedicine, Keppel Street. London WC I E 7HT,UK. Fax: +4417/6367843. Valerie Curtis is apublic-health engineer in LSHTM's Maternaland Child Epidemiology Unit. Fax: +44171637Jl73.

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1S:2isHygienic tortilla preparation, storage, and reheating practices will reduce thelikelihood of diarrhoea.

World Health Organization, Geneva, 1993.4. Cunis, V. et 01., 'Structured observation of

hygiene behaviour in Burkina Faso: Validity,variability, and utility. Bulletin of WHO,VoL71. No.1, 1993, pp.23-32.

5. Almedom. A. et 01., 'Dodoma hygieneevaluation study'. Repon to WaterAid andthe Environmental Health Programme, Lon-don School of Hygiene and Tropical Medi-cine, London, 1994.

6. Almedom, A., 'Gender issues in urban watersupplies'. Ethiopia 12 towns water supplyand sanitation study. Working Paper No.6,Provisional Government of Ethiopia. WaterSupply and Sewerage Agency and GibblSeureca, Addis Ababa. 1994.

7. Cairncross, S. and Kochar. V. (eds.), Study-

() Water-related hygiene hehaviourElena Hurtado and Elizabeth MillsBooth's article describes succinctlythe process of developing an effec-tive communication intervention inGuatemala aimed at improvinghandwashing practices, therebyreducing diarrhoea.

() Water quality and use A detailedqualitative study conducted inSukumaland, Tanzania, investi-gated the socio-cultural constraintson the use and maintenance ofimproved water sources. Jan-OlofDrangert contrasts the villagers'traditional notions of water 'quality'with the Western bio-medicalconcept of contamination; high-lights the complexity of the prob-lem; and outlines the role of anthro-pologists in informing interveningagencies.This issue of Waterlines will, we

hope, arouse interest in practical effortsto integrate the 'software' aspects ofwater supply and sanitation interven-tions with the 'hardware'. A 'hygiene-behaviour network' has been set upunder the Global Applied ResearchNetwork (GARNET) of the Collabora-tive Council for Water Supply andSanitation. Interested readers shouldcontact Astier Almedom, direct, formore information .•

cifically at water handling; hand-washing before handling food; foodpreparation; and storage and reheat-ing. The authors discuss the issuesinvolved in trying to establish hy-giene-behaviour barriers to thetransmission of faecal pathogensfrom fingers and food to mouth.

() Excreta disposal The results of aseries of qualitative studies (includ-ing quantifiable data) conductedwith the aim of field-testing severalmethods and tools for hygieneevaluation, in collaboration withselected health-education, water-supply and sanitation project staffin East Africa, are summarized byAstier Almedom and Ashoke Chat-terjee. They propose some effectiveand measurable indicators for sani-tation, and discuss their practicalapplicability and use.

ReferencesI. Bern, C. et 01., 'The magnitude of the global

problem of diarrhoeal disease: a ten-yearupdate', Bulletin of WHO, VoL70, No.6,Geneva, 1992, pp.705-714.

2. Warren, K.S. et 01., 'Helminth infection', in8.

3. 'Improving water and sanitation hygienebehaviours for the reduction of diarrhoealdisease', Report of an informal consultation,

In April's issueWe look at the Ie hnique mall holders u to irrigate lh ir crop . WFoeu • in particular. on how farmers develop and hape t hn I gie t fildiffi rent phy ical and oeial environmen nltibu~ I e amin thupportive role f e terna! agencies.

WATERLINES VOL.13 NO.3 JANUARY 1995 5