Hygiene - Introduction

ENVR 890

Mark D. Sobsey

Spring, 2007

Hygiene Promotion: One of the Big Five to Reduce Diarrheal Disease

Hygiene: The Importance and Impact of Handwashing

• Handwashing with soap and water after contact with fecal material can reduce diarrheal diseases by 42%% or more– Curtis, V and S. Cairncross

(2003) Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis. 2003 May;3(5):275-81.

Washing Hands• One of the most effective behaviors to prevent diarrhoea,

roundworm and whipworm. • Rarely done at the most crucial times and rarely done most

effectively (with soap). (Is soap really needed?)• Hands get most dangerously contaminated fron human faces

and soil (possibly containing worm eggs). • Crucial times for handwashing to reduce transmissions are:

– after defecation and after contact with children’s faeces– before handling food and after handling high risk food

such as raw meat– before eating and before feeding children– before handling water.

• Effective handwashing requires thorough rubbing of the hands while using soap and sufficient water to rinse it off.

• If soap is not available, ash or earth is nearly as effective• Water alone is effective, especially of water is clean

Cleaning fingernails

• Closely related to handwashing. • Handwashing does not ensure fingernails get cleaned • Clean fingernails are particularly important when food is

consumed or fed to infants using fingers– Clean fingernails have an aesthetic value

• Handwashing and cleaning fingernails also play a role in the prevention of eye and skin infections, such as scabies.  – When wiping infected eyes or scratching itching

infected skin, bacteria or mites can settle on fingers and hence be transmitted.

•  Keeping fingernails clean requires them to be kept short and brushed regularly.

Washing the body (bathing)

• Important for preventing skin infections like scabies (caused by small mites living under the skin), and ringworm (a fungal infection).

• Also louse-borne typhus and louse-borne relapsing fever are controlled with regular washing of the body and clothes.

• Washing is best done using running water and soap– Special attention needs to go to folds of the skin

as well as to skin between fingers and toes.

Washing the face• Has an important role in the prevention of eye-

infections• Hygiene related eye infections are conjunctivitis and

trachoma• More frequent washing of the face and few flies sitting

on eyes reduces the incidence of trachoma • Washing the face regularly removes infectious

discharge from the eyes. • This prevents flies from being attracted to the infected

eyes, thus becoming transmission agents. • Removing eye discharge using bare fingers or a cloth,

causes bacteria to be picked up on the fingers or cloth and transmitted to anything else that they touch.

Washing clothes and bedding• Major preventive measures to reduce

transmission of scabies and louse-borne typhus and relapsing fever.

• Touching clothes or bedclothes of a person infected with scabies or ringworm can easily cause spread and further infection of others

• Lice, which may spread typhus or relapsing fever, hide in seams of clothes and bedclothes– Washing removes them– Communal use of clothes and bedclothes should be

avoided

Introduction and Issues

• The most important lesson learned from water and sanitation programmes:– water and sanitation facilities on their own do not

result in improved health. – Access to improved facilities is crucial, but…– Correct use of water and sanitation facilities is what

leads to a reduction in disease

• Correct use requires personal, community and institutional actions– actions depend on behaviors

Hygiene and Behavior• Hygiene is a key factor in reducing risk of diarrheal and

other sanitation-related diseases• People and communities can protect themselves from

diarrhea and other infectious diseases they make changes in hygiene behavior

• Making behavior changes requires actions• These behavior change actions will occur only if people

are informed– They need information about how and why certain

personal and community behaviors will reduce disease transmission risks

– They need encouragement to make positive changes in their hygiene behavior.

– Hygiene education is essential to achieve hygiene behavior change.

UNICEF Hygiene Improvement Framework

Access to Facilities• Implement and promote a package of

appropriate, low-cost sanitation, water and hand washing facilities

• Introduce basic technologies that may be upgraded when families and communities can afford to do so

Hygiene Awareness and Promotion

• Focus on behavior change by communicating key hygiene practices like hand washing.

• Encourage children, youth and mothers to be agents of change in their families and communities

• Implement through initiatives such as lifeskills training programs, curriculum development and integrated sanitation and hygiene education in schools, and maternal and child health education

Enabling Environments(and Institutions)

• Promote hygiene continuously at all levels– Village household– Village or community– District, province, canton, etc– Nationally– Regionally– Globally

• Developing national policies is critical • UNICEF focuses on promoting community-managed

systems that are affordable and easy to maintain. – Equip communities with the knowledge and skills to effectively

manage their own facilities– Encourage communities to demand high-quality service from

duty-bearers in government, civil society and the private sector

Enabling Conditions

• The most obvious enabling condition for personal hygiene is the availability of water.

• However, for behavioral change to occur and be sustained there is a need to continue hygiene promotion until the new behavior has become entrenched

Hygiene Promotion Key Principles

1. Target a small number of risk practices

2. Target specific audiences

3. Identify the motives for changed behavior

4. Hygiene messages need to be positive

5. Identify appropriate channels of communication

6. Decide on a cost-effective mix of channels

7. Hygiene promotion needs to be carefully planned, executed, monitored and evaluated.

Hygiene Promotion: Target Practices Having a Positive Health Impact

The Big 3:• Handwashing with soap (HWWS)• Removal of stools (feces) from the household

environment• Home treatment and safe storage of drinking

water

Others:• Safe disposal of children's stools• Safe handling of weaning food

Identifying Behavioral Domains for Hygiene

Five Behavioral Domains (Boot and Cairncross, 1993)

• Disposal of human faeces• Use and protection of water

sources• Water and personal hygiene• Food hygiene• Domestic and environmental

hygiene

Personal Hygiene Behaviors:• Washing of hands / cleaning of nails • Washing of face • Body wash / bathing • Hygiene after defecation • Washing and use of clothes, towels and bedding

Personal Hygiene Measures(Benenson, 1990)

• washing hands in soap and water immediately after fecacation/urination and always before handling food or eating 

• keeping hands and unclean articles, or articles that have been used for toilet purposes by others, away from the mouth, nose eyes, ears, genitalia, and wounds

• avoiding the use of common or unclean eating utensils, drinking cups, towels, handkerchiefs, combs, hairbrushes and pipes

• avoiding exposure of other persons to spray from the nose and mouth as in coughing, sneezing, laughing or talking

• washing hands thoroughly after handling a patient or his/her belongings and 

• keeping the body clean by sufficiently frequent soap and water baths.

Hygiene Promotion for Children• Most hygiene promotion is developed for adults • Young children do not possess the same skills,

knowledge and ability to learn complex concepts as older children (or adults), and they learn differently

• Children learn through:– Helping (e.g., with chores)– Playing– Being creative– Dealing with others (interaction and communication)– Playing– Exercising

Hygiene promotion in Schools

• School sanitation and hygiene education (SSHE)• Combination of hardware and software components to

produce a healthy school environment and to develop or support safe hygiene behaviors.

• The hardware components:– drinking water– hand washing– excreta disposal– solid waste disposal facilities in and around the school

compound.

• Software components: activities that promote conditions at school and practices of school staff and children that help to prevent water and sanitation-related diseases and parasites

Benefits of School Hygiene and Sanitation• Effective learning: Children perform better when they

function in a hygienic and clean environment. • Increases enrolment of girls: The lack of private

sanitary facilities for girls can discourage parents from sending girls to school and contributes to the drop out of girls, particularly at puberty.

• Reduces incidence of disease and worm infections: If school sanitation and hygiene facilities are absent, or are badly maintained and used, schools become health hazards.

• Environmental cleanliness: Presence and proper use of facilities prevents pollution of the environment and limit health hazards for the community at large.

• Implementing children’s rights: Children have the right to be as healthy and happy as possible. Being clean, healthy and having clean water and proper sanitation facilities contribute to a happy childhood.

Issues in School Hygiene Education• Developing and producing teaching materials:

– hygiene education materials which can be reproduced on a large scale, so that they are not too costly and allow for easy adaptation to local circumstances.

• Basic insights into the more technical aspects of sanitation facilities at the school:– Teacher training on how sanitary facilities work in practice which includes the

construction, operational and maintenance aspects. • Organizational issues of sanitary facilities:

– Includes ways to monitor behavioral changes.• Focusing of teacher training:

– How to use the materials of SSHE; – how to organize/implement a SSHE programme– How to plan for the replacement of facilities.

• Outreach programs to the community:– To gain community support– To ensure that the learned behaviour can also be practiced at home.

• Focusing on monitoring:– Evaluation and documentation of SSHE experiences for teachers in schools

around the world.

School Hygiene Program Strategy• Striving for a common goal, common purpose, common

policy and common planning

• Focusing on the child as the key resource

• Focusing on schools as the knowledge centre

• Focusing on education for behavior change

• Acknowledging the teacher as the facilitator

• Concentrating on result oriented/effective delivery system

• Recognizing that the community is an equal partner

Five Fallacies about Hygiene Promotion

• Fallacy No. 1. Behaviour change is easy.

• Fallacy No. 2. Knowledge change=behaviour change.

• Fallacy No. 3. Experts know how to change behavior.

• Fallacy No. 4. A whole variety of hygiene practices should be encouraged.

• Fallacy No. 5. Hygiene promotion is a cheap add-on to water programmes.

Lessons from Marketing and Private Industry: Public-Private Partnerships

• Private Industry is very successful at changing behavior– Its survival may depend on it!

• Soap companies have got soap into almost every household in the world.

• They can thus be useful partners in promoting HWWS. • Knowledge sharing between public and private sectors

has created a Global Public-Private Partnership for Handwashing.

• Several country programmes are underway• Successful experiences have now been collated into the

Handwashing Handbook – (Scott et al, (2005), a practical guide to handwashing promotion

at the national level.  

Understanding Consumer Behavior: A Key Principle• Base handwash promotion

programs on an understanding of consumer behavior

• First stage: conduct comprehensive formative or ‘consumer’ research (see Fig) to answer four essential questions: – What are the risk practices? – Who carries out the risk

practices? – What drivers, habits and/or

environment can change behaviour?

– How do people communicate? • Next: Use the answers to design an

appropriately targeted promotion campaign.

Hygiene Improvement Framework