Hygiene: Diarrhoea, Disgust and Desire

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Hygiene Diarrhoea, Disgust and Desire
Valerie Curtis
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Objectives

• Hygiene in environmental health
• Behaviour change 2 perspectives
• Understanding consumer behaviour
• Programme design

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QUIZ
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  1-     How many people die every day from
diarrhoeal diseases? a.      600 b.     
1,000 c.       6,000 d.      10,000
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  2.     Which of these is the most
dangerous? a.      Cars b.      Lions c.     
Dirty water d.      Faeces
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  3.    Which of the following has the highest
impact on reducing diarrhoeal disease? a.     
Improving water supplies b.      Hygiene
education c.      Washing hands with soap d.     
Sanitation
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4. Which sector is the worlds biggest
advertising spender? a.      Car
manufacturers b.      Politicians c.      Soap
and detergents d.      Aid agencies
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5. By about how much could handwashing with soap
reduce diarrhoeal infections? a.      22 b.     
47 c.      66 d.      100
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 6. How many times a month do you need to hear a
message to be likely to change your
behaviour? a.      once b.      twice c.      six
times d. twenty times
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  7. Which message is most likely to get people
to wash their hands? a. Use soap for pure,
clean-smelling hands. b. If you dont wash your
hands your children will die c.   You dont like
looking dirty? Then wash your hands you fool! d.
Washing your hands with soap will save you money
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 8. Which of the following can be prevented by
washing hands with soap? a.      Diarrhoea
b.      Cholera, dysentery and typhoid c.     
Respiratory tract infections d.      All of the
above  
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 9. What excuse did you have last time you
forgot to wash your hands with soap after the
toilet? a.      I was in a hurry b.      I didnt
like the soap they had c.      There was no
soap d.      Other  
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?
Hygiene
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emic
Hygiene
etic
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emic
insider view
outsider/ scientific view
etic
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emic
intervention
etic
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Etic views of hygiene
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2-3 M deaths
1 Bn episodes per year

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Interventions vs Diarrhoea
risk reduction
water quality
water quantity
sanit-ation
hygiene prom
hand wash
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10,000,000 bacteria
1,000,000,000,000 viruses
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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Fluids
Fields
New Host
Faeces
Foods
Flies
Fingers
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The brimmings of cesspits, the green rot of
markets, the scum of the sewers, the swill of the
gutters, the stench of offal, the vapour of
privies, the lint of navels, the foulings of
footpaths, the footbaths of postmen, the oilings
of lechers, the slime of ruttings, the
scale-cakes of fish stands, the squirtings of
cats, the dribblings of ancients, the pap of
infants, the navel-cords of outcastes
Sealy, The Trotter-Nama, 1996
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Systematic Review and Meta-analysis
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• Inclusion criteria
• Any date
• In English
• ORs, RRs, CIs
• HW alone

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• 38 HW studies located, 17 met above criteria
• 7 intervention, 10 observational
• 10 Asia, 3 Africa, 2 LA, 1 US, 1 Aus
• 9 urban, 5 rural, 1 both, 1 camp
• 14 domestic, 3 childcare

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• All had methodological flaws
• 2/7 randomised
• Oral report of HW
• 2 had good compliance data
• 2 soap not specified

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17 studies of HW and DD RR 1.73 (1.37-2.17)
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7 intervention studies RR 1.88 (1.31-2.68)
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• Limitations of the review
• Weak studies
• No RCTs
• Publication bias
• Mortality uncertainties

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Handwashing with soap could save over a million
lives a year...
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Handwashing with soap could save over a million
lives a year... and prevent ARIs, SARS
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Vectors of infection
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Ignaz Semmelweiss 1818-1865 The aetiology, the
concept and the prophylaxis of childbed fever
1861
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WASH YOUR HANDS!
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WASH YOUR HANDS!
Or else...
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The Health Belief Model.
Becker et al, 1974
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The PRECEDE model for health promotion planning.
Green and Kreuter, 1991
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Behaviour change weve learnt a lot
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Emic views of hygiene
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Everybody wants to be clean
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KLEEN-IT
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Disgust
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India Faeces, urine, toilets, sweat, menstrual
blood, spilt blood, cut hair, impurities of
childbirth, vomitus, smell of urine, open wound,
saliva, dirty feet, eating with dirty hands, food
cooked whilst menstruating, bad breath, smelly
person, yellow teeth, nose picking, dirty nails,
worn clothes, flies, insects, maggots, lice,
mice, mouse in curry, rats, dogs, stray dog,
meat, fish, pigs, fish smell, dog or cat saliva,
lizards, flies on faeces, liquid animal dung,
soap that has been used for the latrine, dead
animal, dead rat, rotting flesh, parasitised
meat, wet cloth, stickiness, decaying waste,
garbage dump, sick person, hospital waiting
rooms, beggars, touching someone of lower caste,
crowded trains, lower castes, alcohol, nudity,
kissing in public, betrayal. (Data collected in
6 FGDs with women and 50 essays on the subject of
impurity by teenage girls in Lucknow.)
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UK Faeces, dog shit, cat shit, dog diarrhoea,
vomit, wounds, wounding an old lady, maggots,
sweaty person, body parts in jars, stained
toilet, stained kitchen, flies, dead sparrow,
rotten food, mouldy food, rank smell of old
grease, foul language, dirty nails, drunks,
drunken louts, rude people, eating with mouth
open, eating a burger that a stranger had bitten
into, cleaning anothers false teeth, dirty
hotel, dirty cafeteria, dirty play area, man
beating a woman, cruelty to a horse (Essays on
disgust provided by 26 members of Unilevers
consumer panel in Cheshire, UK in 1999)
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Netherlands Faeces, hairs, vermin, vomit,
dust, sweat, stickiness, offal, fish mongers
hands, cats, dogs, dog hairs, dog saliva, rotten
waste, bad smelling food, food leftovers, worms,
flies, aphids in lettuce, pollution, drug users,
drunkenness, fat people, insulting behaviour,
politicians, dirty old man (Data collected in
in-depth interviews with mothers of small
children in Gelderland and Eindhoven. Data
analysed with QSR NUDIST )
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Darwin 1872
Six basic emotions Sadness, happiness, anger,
surprise, fear and disgust
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Disgusting things are Bodily secretions, body
parts Certain animals and insects Signs of
decay, waste, off food Other people
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Q. Why are they disgusting? A. Because being
disgusted helped our ancestors avoid disease
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• Hygiene protects the vulnerable ports of entry
• skin
• airways
• GI tract
• genito-urinary system

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Disgust a key hygiene motivation
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Stimuli Bodily secretions
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Effects Age
Female
Male
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Micro-parasites
Macro-parasites
v
v
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If my child is dirty then no-one wants to hold
him in their arms I wash my hands after
smoking a cigarette because of the baby
Nurture
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Flowers and greenery are purifying I clean
to make my house beautiful
Aesthetics
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When some VIP is coming I get out the phenyl to
clean the floor I clean so my mother-in-law
wont find anything to comment about
Respect/dignity
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• Hygiene motivation
• nurture
• disgust
• aesthetics
• order
• respect/dignity

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• But
• Globally, hands are washed with soap on less than
  20 of the occasions when they should be.

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emic
intervention
etic
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Structured observations of handwashing behaviour
latrine
SANIYA
soap/child
soap/toilet
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Partners World Bank, WSP, Unicef, USAID, WHO
LSHTM, AED, CDC Unilever, PG, C-P, small-scale
producers and MF associations Govs of Ghana,
Peru, Senegal, Nepal, Indonesia and Madagascar
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P
P

• Government
• Health, social welfare and
• Educational infrastructure
• Local-level institutions
• Resources and expertise

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• Private sector
• Crafting communication for behaviour change
• Program design and control
• Optimising resources across channels and media

• Scientific community
• Defining scope and thrust of the program
• Credibility
• Knowledge capture and dissemination

• ESAs
• Financial resources
• Past experience

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• Ghana
• Consumer behaviour research
• Practices
• Motives
• TAs
• Channels of communication

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PPP Handwash (Ghana)
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Communication research 1. Consumer research 2.
Concept testing 3. Materials testing
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• What do I need to know?
• What is the problem?
• Who are the target?
• Why should they change?
• How to reach them?

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Behaviour research
Communication plan
Target practices
What are risk practices?
Primary target audience
Who is causing risk?
Message positioning
What drives practices?
Media mix
How do they communicate?
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Behaviour research
Communication plan
Target practices
What are risk practices?
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Behaviour research
Communication plan
Target practices
What are risk practices?
Primary target audience
Who is causing risk?
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Behaviour research
Communication plan
Target practices
What are risk practices?
Primary target audience
Who is causing risk?
Who are they?
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Target Audiences
Opinion leaders
Community leaders
Mothers-in-law
Fathers
NGOs
Mothers Children Child carers
Religious leaders
ESAs
Neighbours
Media
Government agencies
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Behaviour research
Communication plan
Target practices
What are risk practices?
Primary target audience
Who is causing risk?
Message positioning
What drives practices?
Motives?
Barriers?
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Behaviour research
Communication plan
Target practices
What are risk practices?
Primary target audience
Who is causing risk?
Message positioning
What drives practices?
Media mix
How do they communicate?
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Communication Channels
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Channels -gt TAs

• Development of Local Anganwaadis
• Women and child panchayats 96
• program 51 1

Integrated rural Primary Middle Secondary dev.
Program school school School 57 90 87 74
Community Adult TV 62 Education centre
58 Community Primary centre
40 Health centre 74 Fair price
Health sub- shop 91 centres 79 Retail
Private shop 67 doctor 88 Milk Bank
89 Post-office Village health cooperative 89 g
uide 38 67
Target mother
NGOs Traditional birth attendant 49
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MINI-PROJECT find out what motivates handwashing
practices in fellow students so as to get them to
improve. Work in 4s Come up with a list of
motivating factors and some ideas about how they
might translate into a hygiene promotion
programme
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Possible methods -semi-structured
interview -group discussions -behaviour
trial Timing planning, interviewing/trials,
putting it together, presenting
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QUIZ
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  1-     How many people die every day from
diarrhoeal diseases? a.      600 b.     
1,000 c.       6,000 d.      10,000
?
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  2.     Which of these is the most
dangerous? a.      Cars b.      Lions c.     
Dirty water d.      Faeces
?
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  3.    Which of the following has the highest
impact on reducing diarrhoeal disease? a.     
Improving water supplies b.      Hygiene
education c.      Washing hands with soap d.     
Sanitation
?
108
4. Which sector is the worlds biggest
advertising spender? a.      Car
manufacturers b.      Politicians c.      Soap
and detergents d.      Aid agencies
?
109
5. By about how much could handwashing with soap
reduce diarrhoeal infections? a.      22 b.     
47 c.      66 d.      100
?
110
 6. How many times a month do you need to hear a
message to be likely to change your
behaviour? a.      once b.      twice c.      six
times d. twenty times
?
111
  7. Which message is most likely to get people
to wash their hands? a. Use soap for pure,
clean-smelling hands. b. If you dont wash your
hands your children will die c.   You dont like
looking dirty? Then wash your hands you fool! d.
Washing your hands with soap will save you money
?
112
 8. Which of the following can be prevented by
washing hands with soap? a.      Diarrhoea
b.      Cholera, dysentery and typhoid c.     
Respiratory tract infections d.      All of the
above  
?
113
 9. What excuse did you have last time you
forgot to wash your hands with soap after the
toilet? a.      I was in a hurry b.      I didnt
like the soap they had c.      There was no
soap d.      The basin was dirty  
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