Hygiene Behaviour Network Newsletter

Issue no. 2: June 1995

Editorial
Dear Colleague,

Here at last is our second newsletter. Several factors have contributed to its prolonged gestation. Among these were the general delay in getting members' news and funding uncertainties which kept us waiting for a longer than we anticipated. A number of you have sent us some news to share. We would like to thank you all. The exchange of news and sharing of ideas and research findings is the essence of networking. Please keep sending us your contributions and we will make sure they are shared among network members. We would especially like to hear from those of you who have made use of our first network newsletter to contact fellow members whose research areas have been of particular interest to you, and to establish links with them.

We would like to welcome new members who have joined by writing either directly to us through the GARNET headquarters at WEDC. Thanks are especially due to Eva Kaltenthaler who not only joined but also contributed some of her research results to share with you. The findings of the Leeds study may be of particular interest as very few hygiene behaviour studies have been reported from developed countries. The postal addresses and contact numbers of new members' are to be found at the back on the last page of this issue.

Along with members' news, this issue features more than ten references (with abstracts) of hygiene behaviour studies published in various academic journals during the last five years. We collected these references by searching through databases such as "Medline" and "Embase" using our desk-top computers which are connected to various electronic networks. We hope these references will be of interest and some use, especially to members who have no access to such electronic facilities. Author(s) contact addresses are included to enable you to send for reprints of articles that may be of particular interest to you. On the subject of electronic networks, GARNET is now on the interned Members who have access to electronic network facilities should contact Darren Saywell, the co-ordinator, at this address: D.L.Saywell@lboro.ac.uk

We wish you success in your work, and look forward to receiving your news, comments, and suggestions concerning the format, style and content of this newsletter. Thank you.

Astier Almedom and Caroline Smart
Editors

Network News

Eva Kaltenthaler, a microbiologist who completed her doctoral research work last year has joined our network. Eva sent us the following contribution.

Studying hygiene behaviour
Methods used to study hygiene behaviour can be applied to a variety of settings. The following two studies were very different yet were both successful in identifying hygiene problems specific to those settings. The first was a study of hygiene behaviour and its relationship to childhood diarrhoea in northern Botswana and the second involved investigating hygiene behaviour in primary schools in Leeds, England.

In Botswana, as in many developing countries diarrhoea continues to be a major cause of childhood morbidity and mortality. In order to investigate the relationship between hygiene behaviour and diarrhoea a variety of methods were used, both quantitative and qualitative. In order to gain information concerning what mothers felt were the causes, treatment and prevention of diarrhoea, focus groups, key informant interviews and in-depth interviews were used. Observations were conducted in order to determine what hygiene behaviours were actually occurring in the home. Ideas about handwashing were felt to be important and to explore this in depth interviews and focus groups were used. These simple methods were effective in gathering a large amount of information concerning traditional beliefs and practises relating to diarrhoea and hygiene behaviour. Such information should form an integral part of successful health education programmes.

In Leeds, many outbreaks of gastrointestinal infections have been associated with primary schools. In this study again a variety of quantitative and qualitative techniques were used to gain information on hygiene behaviour. The knowledge of young primary school children regarding hygiene was assessed by using a questionnaire. In-depth interviews were conducted with teachers, nursery nurses and caretakers to identify hygiene problems. Observations were also carried out to identify hygiene problems. These findings were presented to the Department of Education and it is hoped that some of the recommendations in the report will be applied to primary schools to ensure more adequate provision of supplies as well as greater emphasis on teaching hygiene.

The main qualitative findings for the Botswana Study included information on the causes of diarrhoea and reasons for handwashing.

Table 1. Causes of diarrhoea

Traditional:

• pogwana (sunken anterior fontanelle);
  
• child is bewitched;
  
• bad breastmilk due to unfaithfulness of mother;
  
• child meets someone taking traditional medicine; and
  
• mother is pregnant.
  

Physical:

• teething;
  
• measles;
  
• malnutrition;
  
• flu or other illnesses;
  
• worms in the stomach;
  
• fever; and
  
• abdominal pain.
  

Food:

• watermelon;
  
• dirty food or water (contaminated with germs);
  
• eating dirt;
  
• improper food or certain foods (spinach or cabbage for example);
  
• corn soya milk with no oil added; and
  
• too many different foods given in one day.
  

Environmental:

• cold weather.
  

Reasons for handwashing are described in table 2 below.

Table 2. Reasons for handwashing:

• to remove contamination or "dirt";
  
• for cosmetic reasons;
  
• for comfort; and
  
• handwashing before meals is thought to be sufficient.
  

Adult human faeces and menstrual blood were among things perceived to be most contaminating. Infant faeces and cow dung were not considered to be dirty.

In the Leeds primary school study a story about Mr Smiley was used to assess hygiene knowledge among the reception class children.

The results for question c were 392 (72%) said wash his hands, 30 (6%) said something else and 122 (22%) said they didn't know. For question d 354 (65%) said he should wash his hands, 18 (3%) said something else and 172 (32%) said they didn't know. When asked why handwashing was important 175 (33%) said to remove germs, 56 (10%) said to remove dirt, 291 (54%) said they did not know why it was important and 15 (3%) said because their mother said so. Children's knowledge was strongly associated with what they learned at school.

Each child was given a hygiene knowledge score based on the number of correct answers. This was compared with the faecal contamination found on the child's hands. An association was found between this score and the hand counts: relative risk = 1.4, cl= 1.09-1.81, p= 0.005. From the interviews with teachers, caretakers and nursery nurses the following issues presented in table 3 were considered important.

Table 3. Problems identified through interviews

• lack of supervision in the toilets floors were often flooded due to taps being left running; (large quantities of toilet paper in the toilets often caused blockage);
  
• lack of hygiene knowledge in children at school and no backup from home; and
  
• inadequate provision of soap, hand towels and toilet paper in some schools.
  

References:
Kaltenthaler EC (1994). Hygiene behaviour and childhood diarrhoeal diseases. PhD thesis, London School of Hygiene and Tropical Medicine.

Kaltenthaler EC, Elsworth AM, Schweiger MS, Mara DD, Braunholtz DA (1994). Hygiene assessment in selected primary schools in Leeds. Final Report, Department of Civil Engineering, University of Leeds.

Koronel M.P. Kema, a public health engineer, sent the following description of his research.

Title: Hygiene behaviour, water use and sanitation practices.
Subject: Water supply, sanitation, engineering and environment.

"The research looks into the existing water sources and sanitation options available in Dodoma Region, Tanzania. It looks at how these systems are being handled and utilised by the beneficiaries bearing in mind their cultural beliefs etc. For urban, it looks at solid-waste handling and drainage systems or on-site waste water disposal."

This work is being done despite the lack of funding support, out of Mr. Kema's interest and dedication to the subject. Mr. Kema's department provides some logistical assistance in the form of transportation as part of WaterAid-supported project activities.

Sarah Bradley, a medical sociologist, contributed the following information about her book entitled How People Use Pictures.

"All people develop skills in visual literacy. Yet because of cultural and social differences, we interpret visual symbols and representations in different ways. How People Use Pictures focuses on how and why people use visual images to represent ideas and processes. The first comprehensive literature review on visual literacy in over a decade, it is suitable for practitioners interested in communicating with local people using pictures and visual symbols, and for researchers interested in gaining a deeper appreciation of the "language of the visual". The book also provides detailed annotations of over 100 key references, as well as an extensive list of useful institutions and visual resources.

This book is part of the IIED Participatory Methodology Series. This series provides a range of materials on participatory learning and action methodologies for development, and is aimed at trainers and practitioners alike. The series has grown out of work conducted by IlED's Sustainable Agriculture Programme, whose staff have been actively involved in braining and research since 1986. Theproduction of the book was supported by the British Council."

How People Use Pictures will be available from the end of July. To order a copy, contact:
The Book Shop,
International Institute for Environment and Development,
3 Endsleigh Street,
London,
WC1H ODD,
U.K.

Tel: +44-171-388 2117
Fax: +44-171-388 2826

John Pinfold, a hygiene education specialist, wrote with an update on the WaterAid (Uganda) activities he is co-ordinating.

"We have been developing participatory methods for promoting hygiene behaviours. These methods have been adopted from some PRA/PROWWESS techniques for:-

• collecting information about traditional water sources and patterns of water use;
  
• discovering roles and activities of water and sanitation committees;
  
• operation and maintenance;
  
• community selection of hygiene behaviours in view of constraints to behavioural change; and
  
• monitoring and evaluation of water/sanitation activities.
  

Results thus far have been very encouraging and we will be developing a description and examples of all these methods for distribution shortly."

Sandy Cairncross, senior lecturer in public health engineering, is now back in the London School of Hygiene & Tropical Medicine after two-and-a-half years with UNICEF in a regional interagency team to support Guinea worm eradication in West Africa. Guinea worm is disappearing fast, thanks to programmes which are successfully stimulating a simple change in hygiene behaviour: filtering water through a cloth.

Graphical evidence from this research shows how health education had at least as great an impact on Guinea worm disease as water supplies in Enugu State, Nigeria. The solid line shows the number of cases detected by active village-based surveillance in 77 villages where boreholes were drilled in the six months to April 1990, and the dotted line is for 30 comparable villages in a nearby district which was not covered by the water project. The boreholes are likely to have cost at least US$ 10,000 per village. All 107 villages were covered by a vigorous health education campaign costing US$ 110 per village per year, accompanied by the distribution of cloth filters.

The significant effect of the boreholes in reducing the number of cases one year after their installation is clearly demonstrated in this work (Guinea worm has an incubation period of one year), but is dwarfed by the greater and more sustained impact of the vigorous health education which covered both sets of villages. Of course water supply has other benefits besides Guinea worm prevention, but this work does show what can be achieved by behaviour modification alone.

Source: Braide E.l. et al. (1994) Impact of JICA boreholes on the incidence of Guinea worm disease and school attendance in Enugu State. Calabar, Nigeria: Nigeria Guinea Worm Eradication Programme.

Simon Cousens, a medical statistician/epidemiologist, has contributed the following detailed description of a project his research team is working on.

Project Saniya, Bobo-Dioulasso, Burkina Faso
"Work on the development and implementation of a communications programme to change selected hygiene behaviours has been continuing in Bobo-Dioulasso with funding from UNICEF. Towards the end of 1994, a pilot scheme was established in one sector of the town, with a population of about 10,000 inhabitants. Initially a meeting was held with the Management Committee of the local health centre (which is one of the first health centres in Bobo-Dioulasso to implement the Bamako Initiative). Members of the Committee responsible for Liaising with the Women's Associations in the area informed women in the community of a "Djanjoba" (public meeting) to be held to introduce and discuss the Programme.

Following the "Djanjoba", the area was divided into 25 sub-areas and a rapid census of the area performed by the Agents de Liaison (project staff). At a second public meeting, elections were held at which each sub-area elected a "Responsable Saniya" (hygiene monitor) from among the women living in the sub-area, to promote and monitor the Programme's target behaviours. The 25 Responsables were given 3 days' training, focusing on inter-personal communication, leading of public discussions, visiting courtyards and recording observations, and knowledge of diarrhoea and its prevention. During the training the Responsables helped to design a simple observation form for use by non-literates.

After the training period, each Responsable went back to her own sub-area and called a meeting of residents at which she reported on the training she had received and on the activities that she would undertake.

During the first week of fieldwork the Responsables worked closely with project staff. After one week they began to work independently, going out three mornings each week in order to visit each courtyard in their sub-area once per week, encouraging mothers to adopt the target behaviours and making simple spot observations of the presence of potties and stools. In addition, once a fortnight they organise neighbourhood clean-ups of the streets in their sub-area. Subsequently, the Responsables Saniya received training on the home management of diarrhoea and on the signs which indicate that medical care should be sought. This training conformed with the policy of the National Diarrhoea Control Programme, which is very similar to WHO's own recommendations.

After 22 months of the pilot project, its activities were evaluated by a cross-sectional survey conducted among 50 randomly chosen mothers of young children. Five influential male members of the community were also interviewed individually. In addition, meetings were held separately with the Agents de Liaison and the Responsables Saniya to obtain their impressions of how the work had progressed.

The cross-sectional survey demonstrated a high level of coverage achieved by the pilot project. All but one of the women interviewed had heard of the project, while 44 out of 50 reported having been visited at home by their Responsable Saniya. A similar number reported having taken part in a neighbourhood clean-up. Four-fifths of the women could cite at least one of the messages of the project.

There was general agreement among the various people talked to that there had been a visible improvement in the tidiness of the area. It was felt that stools were less evident, that rubbish was better confined to the designated sites, that mothers were paying more attention to keeping their living area clean and tidy. The problem most commonly identified was a lack of necessary infrastructure (lack of soakaways for the disposal of waste water leading some people to throw it out in the street, absence of communal latrines in public places (e.g. the market), too few rubbish skips too far apart). These problems, identified by the community itself, raise questions regarding the sustainability of the project in the absence of any accompanying measures to improve the infrastructure. They indicate that a programme focusing on just a few practices, without addressing other related problems identified by the community, may have only limited sustainability and impact. Contact has therefore been made with other organisations involved in the development of infrastructure to investigate how our activities might best be integrated."

Astler Almedom - I have two pieces of news to contribute:

Hygiene Evaluation Procedures (HEP) - a handbook for fieldworkers
As mentioned in the last newsletter, this project began as part of the ODA-funded Environmental Health Programme operational research activities. Phase I involved the trial/testing of appropriate methods for the systematic assessments of health/hygiene behaviour in the context of water supply, sanitation and health/hygiene education projects, by people working in such projects. A series of trial "hygiene evaluation studies" were carried out in Kenya, Tanzania and Ethiopia with the active participation of field-level project staff in the design as well as execution of the studies. The HEP handbook was then prepared on the basis of results of these consultative studies, particularly drawing on the practical lessons learned.

Additional ODA-funding has now been secured for the second phase of this project. This will involve field-testing the draft handbook in at least two sites different from those used in its development. The handbook will then be revised and peer-reviewed before final publication and dissemination. Those of you who have already expressed interest in field testing this handbook will have had individual letters from me. I shall be happy to send details of what field-testing might involve to anyone else who is interested. Please let me or Caroline Smart know.

Waterlines
Those of you who are regular readers of this practical journal will have seen the January issue which carried five articles on the topic of hygiene behaviour. I was responsible for "minding" this issue which meant that I had to get five articles together on the theme of hygiene behaviour for the editors of Waterlines to do the layout and copy-editing. Unfortunately, despite considerable time spent in liaising with authors and editors/publishers, some errors were printed and had to be corrected by inserting a few lines in the April issue of the journal. Apologies to our colleagues in Kenya and Tanzania who spotted the errors. The lesson learned is, "make sure you can proof-read final versions of your articles before the editors send them off for printing"!

A brief summary of the contents might be helpful to those of you who have not seen this issue. An update of research progress on hygiene behaviour was outlined in the lead article (Almedom and Curtis). The second article proposed some effective and measurable indicators for sanitation and discussed their practical applicability and use (Almedom and Chatterjee). The third article described some important findings of a detailed study which investigated the socio-cultural constraints on the use and maintenance of improved water sources in Sukumaland, Tanzania (Drangert). The fourth contribution discussed a qualitative study of weaning food hygiene in Guatemala which formed the basis for an educational intervention (de Tejada and Cano). The fifth article described the process of developing an effective communication intervention in Guatemala aimed at improving handwashing practices with the aim of reducing diarrhoeal diseases (Hurtado and Booth).

Recent References (Medline, Embase, etc., 1990-95) with Abstracts

1. Aulia, H. Surapaty, SC, Bahar, E, Susanto, TA Roisuddin, Hamzah, M, Ismail, R (1994). Personal and domestic hygiene and its relationship to the incidence of diarrhoea in south Sumatera. J-Diarrhoeal-Dis-Res. 12(1): 42-8.

Abstract:
The association of risk factors and diarrhoeal disease incidence among children less than 3 years of age in District Rambutan, South Sumatera, was investigated by a 20-week case-control study of 48 households with a high incidence of diarrhoeas diseases and 111 households with low incidence. Among socio-demographic characteristics, television ownership had a significant negative association with diarrhoeal disease incidence (odds ratio [OR] 3.22). The hygiene behaviour significantly associated with diarrhoeal diseases were: disposing of children's faeces in open places rather than in a latrine (OR > 10.47); bathing children in rivers rather than at wells (OR 2.88); children eating with their hands rather than with spoons (OR 5.6); household members defecating in open places rather than a latrine (OR 2.56); house without sewage system (OR 6.98). To control diarrhoeal disease in the study area, we suggest targeting three groups of behaviour for modification: those related to a) faeces disposal, b) sanitary drainage, and c) handwashing with soap and using spoons for eating.

Address:
Diarrhoeal Diseases Research and Study Group,
School of Medicine,
Sriwijaya University,
Indonesia.

2. Rauyajin-O; Pasandhanatorn-V; Rauyajin-V; Na-nakorn-S; Ngarmyithayapong-J; Varothai-C.(1994) Mothers' hygiene behaviours and their determinants in Suphanburi, Thailand. J-Diarrhoeal-Dis-Res. 12(1): 25-34.

Abstract:
The aim of this study was to identify the predisposing and enabling factors affecting mothers' hygiene behaviour in relation to childhood diarrhoeal diseases. Qualitative data were gathered by naturalistic observation of 12 mothers and focus group discussions involving 32 mothers. Mothers with children less than 2 years of age in both urban and rural areas of Suphanburi, a central province of Thailand, were sampled. Twelve local terms describing five different types of diarrhoea were identified. Childhood diarrhoea was classified into two groups depending upon perceived causes: contagious and preventable, and not contagious and unpreventable. To prevent diarrhoea in children, mothers reported that they avoid "taboo" food, avoid breast feeding with "hot" milk and visit local healers for a herbal paste treatment that is applied to the child's throat. Most mothers did not wash their hands before preparing milk or after disposal of children's faeces. However, they did wash their hands after cleaning the child following the child's defecation, and after their own defecation. Our findings suggest that health education programmes should utilise local terminology and work to counter common misunderstandings regarding childhood diarrhoeal disease and its prevention. Knowledge of the predisposing and enabling factors identified in this study will assist in the development of effective implementation programmes.

Address:
Faculty of Social Sciences and Humanities,
Department of Social Sciences,
Mahidol University,
Bangkok,
Thailand.

3. Ekanem-EE; Adedeji-OT; Akitoye-CO. (1994) Environmental and behavioural risk factors for prolonged diarrhoea in Nigerian children. J-Diarrhoeal-Dis-Res. 12(1): 19-24.

Abstract:
Prolonged diarrhoea is a particular health concern because it contributes significantly to diarrhoea-related deaths. Studies of risk factors for prolonged or persistent diarrhoea are virtually non-existent in Africa. In the present study conducted in a semi-urban area of Lagos, we used a case-control design to evaluate the roles of household environment, mothers' food hygiene behaviour, and child-care practices as possible risk factors for prolonged diarrhoea in children 6-36 months old.

A total of 628 children were studied. During the 3 1/2 months surveillance period, 166 children became ill with diarrhoea and 20 of the 166 (12.0%) had prolonged episodes (> 7 days). Persistent diarrhoea (> 14 days) accounted for only 2.4% (6 of 251) of all episodes. This analysis of risk factors is focused on the 20 cases of prolonged diarrhoea and 206 randomly selected controls who experienced no diarrhoea during the surveillance period. A significantly high risk of prolonged diarrhoea was found among children who were given ogi, a maize pap, as the main diet (odds ratio = 4.13). Children who were fed mainly with foods bought from street vendors also had a significantly higher risk (odds ratio = 2.91) of prolonged diarrhoea. No association was found between domestic, environmental, and personal hygiene practices and prolonged diarrhoea. Foods from street vendors may serve as one source of diarrhoea illnesses in Lagos and such episodes could be prolonged following repeated exposure, especially in children who are fed mainly with a low-energy and low-nutrient-density diet such as ogi.

Address:
Department of Community Health,
College of Medicine,
University of Lagos,
Nigeria.

4. Kolsky-PJ. (1993) Diarrhoeal disease: current concepts and future challenges. Water, sanitation and diarrhoea: the limits of understanding. Trans-R-Soc-Trop-Med-Hva. 87 Suppl 3:43-6.

Abstract:
This paper reviews the application of epidemiological understanding of diarrhoeas disease to interventions in water and sanitation. Over the past 20 years, great efforts have been made to elucidate the relationships between water supply, sanitation and diarrhoeal disease. At the outset, it was hoped that improved understanding of these relations could provide a rational framework for the planning of public health engineering interventions. This paper also reviews historical and recent perceptions of water, sanitation, and diarrhoea disease, and summarises progress to date. On the one hand, some fundamental ideas about the relative importance of water quality and quantity in the transmission of diarrhoeal disease have changed, and there is increased recognition of the complex interrelationships between interventions, hygiene behaviour and health. On the other hand, our understanding of the impact of interventions is painfully incomplete, and is unlikely to improve dramatically in the near future. While further research can usefully illustrate a variety of interactions in specific contexts, globally applicable planning guidelines and design criteria appear a dangerous will-o'-the-wisp. While we know more than ever before about water, sanitation and diarrhoea, much remains unknown, and is perhaps unknowable.

Address:
London School of Hygiene and Tropical Medicine,
UK.

5. Wilson-JM; Chandler-GN. (1993) Sustained improvements in hygiene behaviour amongst village women in Lombok, Indonesia. Trans-R-Soc-Trop-Med-Hva. 87(6): 615-6.

Abstract:
Fifty-seven mothers in Indonesia were involved in a face-to-face health education programme which encouraged hand-washing with soap. The intervention spanned 4 months and comprised fortnightly visits by 2 community organisers, who supplied free soap. Two years after the intervention, 79% of mothers were still using hand soap, despite the fact that they now had to buy it themselves. The community seemed to be benefiting from a sustained reduction in diarrhoea episodes due to improved hygiene practices.

Address ?

6. Baltazar-JC; Tiglao-TV; Tempongko-SB. (1993) Hygiene behaviour and hospitalised severe childhood diarrhoea: a case-control study. Bull-World-Health-Oraan. 71 (3-4): 323-8.

Abstract:
The relationship between personal and domestic hygiene behaviour and hospitalised childhood diarrhoea was examined in a case-control study of 356 cases and 357 controls from low-income families in metropolitan Manila. Indices of hygiene behaviour were defined for overall cleanliness, kitchen hygiene, and living conditions. Only the indices for overall cleanliness and kitchen hygiene were significantly associated with diarrhoea. An increasing excess risk of hospitalisation with severe diarrhoea was noted as the ratings for standards of hygiene became lower, and this excess risk persisted even after controlling for confounding variables. The implications of our findings for the control of diarrhoeas disease are discussed.

Address:
College of Public Health,
University of the Philippines Manila,
Ermita.

7. Sabchareon-A; Chongsuphajaisiddhi-T; Butraporn-P; Attanath-P; Pasuralertsakul-S; KitSkoon-P; Banchuin-K; Chanthavanich-P; Singhasivanon-V; Kunstadter-P. (1992) Maternal practices and risk factors for dehydration from diarrhoea in young children: a case-control study in central Thailand slums. J-Diarrhoeal-Dis-Res. 10(4): 221-6.

Abstract:
To determine factors related to dehydration from diarrhoea, we conducted a hospital-based case-control study in children aged 24 months or younger who had acute watery diarrhoea and attended Chonburi Regional Hospital in central Thailand during November 1988 through May 1989. The study compared 48 cases who had moderate or severe dehydration with 48 controls who had no dehydration. Both cases and controls belonged to low socio-economic families and were living in urban slum areas. They had adequate health care facilities and access to ORS packets. Overall, 56% of the mothers used ORS solution at home. None of the mothers knew how to administer ORS, i.e. the fluid was not given at the onset of diarrhoea to prevent dehydration, and they gave no more than 60 ml over a 24-hour period to their dehydrated children. They also did not use home fluids. Multivariate analysis of data showed two factors significantly associated with dehydration: children's dirty fingernails that indicated inadequate maternal hygiene-related behaviour (Odds Rabo 6.4; 95% Confidence Intervals 1.5-27.6, p < 0.01), and frequency of vomiting in the 24 hours before rehydration (Odds Ratio 1.3; 95% Confidence Intervals 1.1-1.6, p < 0.001). Cases and controls had similar aetiologic agents and nutritional status. Providing proper education to mothers about oral rehydration therapy with special emphasis on the volume of ORS to be given, along with guidance to improve their personal hygiene should be considered important interventions in reducing the risk of dehydration and deaths from diarrhoea in these children.

Address:
Department of Tropical Pediatrics,
Faculty of Tropical Medicine,
Mahidol University,
Bangkok,
Thailand.

8. Oladepo-O; Oyejide-CO; Oke-EA. (1991) Training field workers to observe hygiene-related behaviour. World-Health-Forum. 12(4): 472-5.

Abstract:
A study is reported from Nigeria on the training of field workers in the making of structured observations on hygiene-related behaviour with a view to improving the control of diarrhoeal diseases. The programme led to a high degree of consistency in the perception and description of such behaviour by the participants.

Address:
Department of Preventive and Social Medicine,
University College Hospital,
Ibadan,
Nigeria.

9. Bailey-R; Downes-B; Downes-R; Mabey-D. (1991) Trachoma and water use; a case control study in a Gambian village. Trans-R-Soc-Trop-Med-Hva. 85(6): 824-8.

Abstract:
Trachoma is prevalent in many arid areas but data assessing the relationship between water use and trachoma are very scarce. This study compared 18 families having one or more active trachoma cases among the children with 16 trachoma-free families in the same village with respect to water use. Potential confounders such as family size, distance to water source, socio-economic indicators, and hygiene behaviour were assessed in the 2 groups. The families with trachoma were found to use significantly less water per person per day for washing children than did the control group (P = 0.033) with no evidence of confounding by the other measured variables. Low amounts of water for washing were also associated with unclean faces and impetigo in the children. if such a relationship can be substantiated it might provide the basis for effective and cheap interventions against trachoma.

Address:
Department of Clinical Sciences,
London School of Hygiene and Tropical Medicine,
UK.

10. Moy-RJ; Booth-lW; Choto-RG; McNeish-AS. (1991) Risk factors for high diarrhoea frequency: a study in rural Zimbabwe. Trans-R-Soc-Trop-Med-Hya. 85(6): 814-8.

Abstract:
Diarrhoea morbidity data were collected prospectively over 22 months from a cohort of young children living in a deprived community in rural Zimbabwe. Despite the general high prevalence of diarrhoeal disease, there was considerable individual variability in attack rates. Risk factors associated with high diarrhoea frequency were therefore sought by a questionnaire study on feeding, environmental, educational and socio-economic factors. This was supported by observation of living conditions, and water and sanitation facilities. Surprisingly, no association was found between diarrhoeal morbidity and any of these factors, suggesting that other factors such as individual hygiene behaviour or individual susceptibility to diarrhoea may play a role in determining the observed differences in diarrhoea rates in this community.

Address:
Institute of Child Health,
University of Birmingham,
UK.

11. Ekanem-EE; Akitoye-CO; Adedeji-OT. (1991) Food hygiene behaviour and childhood diarrhoea in Lagos, Nigeria: a case-control study. J-Diarrhoeal-Dis-Res. 9(3): 219-26.

Abstract:
We investigated food hygiene-related behaviour as well as other risk factors for diarrhoea in children 6-36 months of age in Iwaya community in Lagos, Nigeria. Between April and July 1989, a bi-weekly diarrhoea surveillance was maintained in 672 households. Following the surveillance, 273 (case = 67 and control = 206) families were visited twice, each visit lasting for 3-4 hours. Detailed observations on food hygiene, water sanitation, and sanitary conditions of the home were made. There was no significant association between any of the observed food hygiene behaviours and the occurrence of diarrhoea. The presence of faeces in and around the toilet area (RR = 1.79), habit of defecating and urinating in chamber pots in dwelling units (RR = 1.80), indiscriminate disposal of waste (RR = 2.48), and source of domestic water (RR = 2.94) were the main factors significantly associated with the occurrence of diarrhoea in this community. These findings imply that diarrhoea might be reduced through an education programme which focuses on the proper care, handling and storage of defecation pots and proper disposal of waste.

Address:
Department of Community Health,
College of Medicine,
University of Lagos,
Nigeria.

12. Bergler-R. (1991) [Hygiene barriers in the hospital-psychological aspects] Zentralbl-Hva-Umweltmed. 191(2-3): 117-58.

Abstract:
This study was made necessary due to the great extent of hospital infections p20,000 cases) in the Federal Republic of Germany and the fact that the nosocomial infection is the most common infectious disease. Starting with a theoretical explanatory model of hygiene behaviour in clinics, 25 senior physicians, 38 assistant doctors, 31 members of the nursing staff and 20 members of the cleaning personnel and domestic staff in university clinics (surgery, orthopaedics, anaesthesia, gnaecology, paediatrics) were examined in a two-stage socio-psychological investigation. To be checked was the hypothesis that the quality and intensity of hygiene behaviour in clinics rises with the extent of personal hygiene sensitivity, knowledge about hygiene essentials, hygiene risks, causes of infection and possibilities of prophylaxis, exemplary and supervisory behaviour on the part of principals and staff in the clinic, as well as the absoluteness, succinctness, clinic-specificity and compulsoriness of rules of hygiene. General findings: (1) During training hygiene was a subject which did not arouse much interest; 57% admit big deficiencies in training; 60.4% of all those asked saw a big lack of information concerning basic knowledge of hospital hygiene, use of non-reusable materials, disinfection of endoscopes, laser probes etc., antibiotic therapy and strategy, development of resistant germs and their disinfection, ways and chains of infection, asepsis in the operating theatre, disposal of contaminated material, rules of hygiene in dealing with HlV-patients, sterilization of implants etc. (2) Doctors and nursing staff assume a relatively high incidence of hospital infections in their own clinic and in their wake an increase in psychological strain on the part of the patients, as well as higher costs in the health service. The most common hygiene deficiencies are lack of space and storage rooms, no separation of septic and aseptic patients, deficiencies in toilets and bathrooms, inadequate personal hygiene behaviour of staff, lack of protective clothing or no regular change of clothing, shortcomings in disinfection, incorrect use of syringes, stethoscopes, etc., no sterile dressings for wounds, no systematic hygiene control and no official consequences for wrong behaviour.(ABSTRACT TRUNCATED AT 400 WORDS).

Address:
Abt. Sozial- und Organisationspsychologie,
Universitat Bonn.

13. Lynch-M; West-SK; Munoz-B; Kayongoya-A; Taylor-HR; Mmbaga-BB. (1994) Testing a participatory strategy to change hygiene behaviour: face washing in central Tanzania. Trans-R-Soc-Trop-Med-Hyq. 88(5): 513-7.

Abstract:
A participatory strategy to increase face washing was designed and tested in central Tanzania. Changing children's face-washing behaviour is postulated to be important in preventing the transmission of eye disease, particularly blinding trachoma. The strategy used non-formal adult education techniques at neighbourhood level meetings to build a community consensus to keep children's faces clean for the prevention of eye disease. Men, women, schoolchildren, traditional healers and village social groups participated in the intervention. The strategy was evaluated by observing changes in numbers of clean faces of a sample of pre-school children in the village. Clean faces increased from 9% to 33% over the course of a year. Factors which were related to sustained change in children's clean faces included distance to water, age of the child, and presence of a corrugated metal roof. Owning cattle was associated with lack of sustainable change in this population.

Address: none given.

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