WELL - Resource Centre Network for Water, Sanitation and Environmental Health

A number of diseases can be prevented by personal hygiene. This fact sheet first defines personal hygiene. It then explores which diseases can be prevented through improved personal hygiene as well as the hygiene behaviour itself. It intends to be supportive to hygiene promoters by looking into some issues of behavioural change and promotional aspects. Last but not least it takes a look at what USAID calls the Hygiene Improvement Framework and its implications for practising hygiene behaviour.

Hygiene behaviour plays an important role in the prevention of diseases related to water and sanitation. Water supply and sanitation make hygiene easier to practice, but the mere provision of facilities has proven to be less effective. In 1991, Esrey found that better hygiene through handwashing, food protection and domestic hygiene brought a reduction of 33% in diarrhoea incidence, whereas improved water supply led to an average reduction of only 15-20%.

Subsequent studies have also shown the health benefits of improved hygiene (Fewtrell et al. 2005). Although the quality of many of the studies is not optimal[1], the general consensus is that hygiene promotion to bring about improved hygiene behaviour and thus health is a worthwhile investment. This fact sheet focuses on personal hygiene as a sub-set of general hygiene behaviour. For more detailed information, see IFH (2002).

Boot and Cairncross (1993) defined hygiene behaviour as the wide range of actions associated with the prevention of water and sanitation-related diseases. One of the five domains of hygiene behaviour which they identified is water and personal hygiene.

Five behavioural domains

Disposal of human faeces
Use and protection of water sources
Water and personal hygiene
Food hygiene
Domestic and environmental hygiene

Boot and Cairncross do not really define personal hygiene, but describe it to include the following behaviours:

Separate mention is made of personal hygiene during natural events such as menstruation, birth, death and illness.

Benenson (1990) is more specific and describes personal hygiene measures to encompass

In this fact sheet, the focus is on those hygiene behaviours that are generally considered to be associated with water and sanitation related diseases.

Different aspects of personal hygiene are of interest to different potential users of this fact sheet.

For policy makers, statistics on the burden of disease are an important source of information when defining their policies. Some of these diseases are water and sanitation related. For defining a policy that seeks to contribute to the prevention of these diseases, they are best served with some general insight in the importance of hygiene promotion. This provides them with a justification for hygiene promotion in their policies.

Water and sanitation programme managers seek information on how hygiene education can increase the effectiveness of interventions such as the construction of water supply and sanitary facilities. This will help them to optimize the allocation of human and financial resources in their programmes.

Hygiene educators, who actually implement hygiene education, may additionally be helped with more details on hygiene behaviours. They need to be well informed about the nature of the behaviour required (e.g. whether it concerns behaviour related to personal or environmental hygiene) and how to address behavioural change in communities.

The pie-diagram below shows how diarrhoea and acute respiratory infections (ARI) make up half of the global burden of environmentally related diseases. Statistics such as these are also available for individual countries.

Much of the transmission of diarrhoea can be prevented by personal hygiene; there is also increasing evidence that hand washing can help to prevent ARI (Cairncross, 2003b).

The table (as attached) shows diseases which can be prevented by improving water and sanitation facilities and hygiene behaviours. It clearly shows the need for hygiene measures, given the role these measures play in cutting disease transmission routes. They can be divided into those that have a positive impact on the cleanliness of the environment and those having a positive impact on the cleanliness of people themselves: handwashing and washing clothes and body. The latter – personal hygiene behaviours – are the focus of this fact sheet.

Managers of water and sanitation programmes wish to improve people’s living conditions by providing water and sanitation facilities. Reducing the distance to water points, improving the quality of water and the safe disposal of human excreta are indeed major improvements. However, they can be further optimized if they include hygiene promotion aimed at improving personal hygiene. Again, the table serves to demonstrate this, but figures comparing the impact of the various interventions are even more powerful. Frequent handwashing is the most important personal hygiene behaviour. Curtis and Cairncross (2002) did a literature review and found that the single personal hygiene practice of washing hands with soap is alone able to reduce diarrhoea incidence by over 40%.

According to Curtis and Cairncross (2003), handwashing with soap and water after contact with faecal material can reduce diarrhoeal diseases by 42%% or more. As indicated in the figure below, a more general review by Fewtrell et al (2004) found something similar.

As we can see from the table, personal hygiene as well as the safe disposal of excreta is important for preventing various types of diarrhoea, trachoma and also roundworm and whipworm,. However, for other diseases (scabies, ringworm, conjunctivitis and louse-borne typhus), personal hygiene is the single preventive measure to take.

Below we will take a closer look at the various personal hygiene behaviours by explaining their meaning for the prevention of disease transmission, their importance and the challenges hygiene promoters face when aiming at motivating people towards behavioural change.

Washing hands is the most effective behaviour for the prevention of diarrhoea as well as for the prevention of roundworm and whipworm. In fact handwashing is widely practised in one form or the other. However, it is rarely done at the most crucial times and done effectively, that is with soap.

Hands get most dangerously soiled through human faeces and earth (possibly containing worm eggs). Therefore crucial moments for handwashing to cut transmissions routes are:

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.

Cleaning fingernails is closely related to handwashing. Handwashing as such does not ensure that fingernails are cleaned also. Whereas clean fingernails have an aesthetic value, from a health point of view they are particularly important when food is consumed or fed to infants using fingers.

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.

Washing the body is another behaviour relevant for the prevention of 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 do not persist with regular washing of the body and clothes. Washing is best done using running water and soap, whereby special attention needs to go to folds of the skin as well as to skin between fingers and toes.

Washing the face plays an important role in the prevention of eye-infections. Hygiene related eye infections include conjunctivitis and trachoma, an eye infection that may eventually cause blindness. Evidence from health research shows that a lower incidence of trachoma is associated with fewer flies sitting on eyes and more frequent washing of children’s faces (Emerson et al 2000). When a person suffers from either of these two infections, washing the face regularly will remove the infectious discharge from the eyes. This prevents flies from being attracted to the infected eyes, thus becoming transmission agents. When the discharge is removed using bare fingers or a cloth, the bacteria can easily be picked up on the fingers or cloth and transmitted to anything else that they touch.

In Nepal and India for example women often use a corner of their sari to wipe a child’s face. If one of the child’s eyes is infected, transmission of the infection or re-infection easily occurs.

Washing clothes and bedding - like washing the body, washing clothes and bedding are major preventive measures for the transmission of scabies and louse-borne typhus and relapsing fever.

Someone can easily be infected with scabies or ringworm if s/he touches the clothes or bedclothes of a person with scabies. Lice, which may spread typhus or relapsing fever, hide in seams of clothes and bedclothes and these should therefore be thoroughly washed regularly. Communal use of clothes and bedclothes should be avoided.

Given the health impact of personal hygiene behaviour, one could easily assume that motivating people to practise it would be quite simple. However, a multitude of factors make effective hygiene promotion rather challenging. In the WELL fact sheet on hygiene promotion, Curtis describes a number of fallacies (ideas which many people believe to be true, but which in fact are false) on which hygiene education programmes are built. One of these fallacies is that new knowledge leads automatically to new practice. Research has indeed shown that this is not necessarily true (Shordt and Cairncross, 2004)

These fallacies indicate the need for an innovative approach to hygiene promotion. Building on field experiences, a number of key principles have been identified.

Key principles for effective hygiene promotion

§ Target a small number of risk practices.

§ Target specific audiences.

§ Identify the motives for changed behaviour.

§ Hygiene messages need to be positive.

§ Identify appropriate channels of communication.

§ Decide on a cost-effective mix of channels.

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

Source: Curtis, WELL fact sheet on Hygiene Promotion

However, for hygiene promotion to be effective, i.e. to lead to actual hygiene improvement, it should not be looked at in isolation. The USAID Environmental Health Project (www.ehproject.org) developed the Hygiene Improvement Framework. This offers a good framework that shows how the combination of hygiene promotion, access to hardware and a conducive enabling environment all contribute to hygiene improvement, including improvements in personal hygiene.

For example: to wash a child’s face one needs access to water and sustainable access to water requires community organizations and well functioning financing and cost-recovery strategies.

The most obvious enabling condition for personal hygiene is the availability of water. However, recent research has also shown that for behavioural change to occur and be sustained there is a need to continue the hygiene promotion until the new behaviour has become entrenched (Shordt and Cairncross, 2004).

More information on how to implement and evaluate hygiene promotion can be found in WELL fact sheets i) Hygiene Promotion, ii) Evaluation of Hygiene Promotion and iii) Social Marketing.

Esrey, S. et al (1991). Effects of improved water supply and sanitation on ascariasis, diarrhea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. Bulletin of the World Health Organization 69(5):609-621..

Boot, M. and Cairncross, S. (1993). Actions Speak. The study of hygiene behaviour in water and sanitation projects. Delft: IRC and LSHTM

Benenson, A. (1990). Control of communicable diseases in man: an official report of the American Public Health Association. 15^th edition. Washington DC.

Cairncross, S. et al (2003a). Health, Environment and the burden of disease; a guidance note. London: Department for International Development.

Cairncross, S. (2003b). Editorial: Handwashing with soap – a new way to prevent ARIs? Tropical Medicine & International Health 8 (8): 677-679

Cave, B. and Curtis, V. (1999). Effectiveness of promotional techniques in environmental health. WELL Study no. 165. London School of Hygiene & Tropical Medicine for DFID http://www.lboro.ac.uk/well/resources/

Curtis, V. and Cairncross, S. (2003). Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infectious Diseases 3: 275-281.

Almedom, A. et al (1997). Hygiene evaluation procedures; approaches and methods for assessing water and sanitation related hygiene practices. International Nutrition Foundation for Developing Countries. Boston, USA.

Emerson, P. et al (2000). Review of the evidence base for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma control. In: Tropical Medicine and International Health, vol. 5, no. 8, p. 515-27.

Shordt, K. and Cairncross, S. (2004). Sustainability of hygiene behaviour and the effectiveness of change interventions; findings from a multi-country research and implications for water and sanitation programmes. IRC, The Hague.

Fewtrell, L., Kay, D., Enanoria, W., Haller, L., Kaufmann, RB. and Colford, J.M. (2005). Water, sanitation and hygiene interventions to reduce diarrhoea in developing countries; a systematic review and meta-analysis. Lancet Infectious Diseases 5(1):42-52.

IFH (2002). Guidelines for prevention of infection and cross-infection in the domestic environment; focus on home hygiene issues in developing countries. Milan: International Scientific Forum on Home Hygiene. http://www.ifh-homehygiene.org/2003/2public/2pub00.asp

Loevinsohn, B.P. (1990). Health education interventions in developing countries; a methodological review of published articles. International Journal of Epidemiology 19 (4): 788-794.

¹ Cave and Curtis (1999( assessed health education studies against criteria developed by Loevinsohn (1990).

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