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