what is hygiene

the scale of the problem

five fallacies

lessons from marketing and private industry

summary of key principles

links with other activities






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Hygiene promotion

Author: Valerie Curtis, reviewed and updated by Lucy Smith, July 2005

Quality assurance: Sandy Cairncross

What is Hygiene?

For health experts, hygiene is behaviour that serves to prevent infection. Hygienic behaviour also helps to keep people and their environments clean, ordered and attractive (Curtis, 2001). Efforts to promote hygiene currently focus around three practices, for which there is strong evidence of a health benefit. These are: handwashing with soap (HWWS), the removal of stools from the household environment and the home treatment of drinking water (see box). The neglect of other practices such as the unsafe disposal of children's stools and the unsafe handling of weaning food can cause health problems in some settings, but has had less attention.

...Hygiene practices help prevent diarrhoea

...Handwashing with soap and water after contact with faecal
...material can reduce diarrhoeal diseases by 35% or more.

Curtis & Cairncross, 2003I

...Using a pit latrine, including for the disposal of children's faeces
can reduce diarrhoea incidence by 36% or more.

...Esrey et al, 1991; Fewtrell et al, 2005

Improving the quality of water at the household level can reduce risk of diarrhoea by 35%

Fewtrell et al, 2005


Hygiene Promotion: the Scale of the Problem

Hygiene promotion is an essential component of water and sanitation programmes. Reductions in diarrhoeal diseases mostly accrue from the improved hygiene practices that improvements in sanitation and water facilities permit (Cairncross & Feachem, 1993). Hygiene promotion can also improve health in the absence of improved facilities (Luby et al, 2004).  

Whilst progress in reaching the Millennium Development Goal (MDG) on water is on track (between 1990 and 2002 around 1.1 billion people gained access to improved water sources), sanitation lags behind; 2.6 billion people still do not have a means of disposing of stools safely and the MDG is not likely to be achieved at current rates of progress (WHO/UNICEF, 2004). Whilst the promotion of “safe hygiene practices” was included as an action required to achieve the water and sanitation goal at the 2002 World Summit on Sustainable Development, it lags even further behind. For example: 

  •  The prevalence of HWWS after defecation is 1% in urban Burkina Faso, 18% in rural Kyrgyzstan, and 34% in Kerala, India; 12% were observed to wash hands after defecation in a Lima shanty town, with the use of soap rare. 

  • HWWS after cleaning up a child who had defecated has been found to occur on less than 1% of occasions in rural Kyrgyzstan, 9.9% in rural Nigeria, 16% in childcare centres in Brazil and 47% in households in Northern England. (Scott et al, 2003).

Improving handwashing practices could save over a million lives globally. Hence the rest of this note concerns the promotion of HWWS. However, similar principles apply to the changing of other practices such as the use of potties to dispose of children’s stools, or safe handling of weaning food.

Five Fallacies about Hygiene Promotion

Fallacy No. 1. Behaviour change is easy.  Getting people to change the habits of a lifetime is difficult, takes time and requires resources and skill.

Fallacy No. 2.  Knowledge change=behaviour change. It used to be thought that education about hygiene would be enough to get people to change their behaviour. However, many people already know about germs, but still don't wash their hands ( Loevinsohn, 1990, Scott et al, 2005). Change may be too expensive or time-consuming, or there may be discouragement from other members of society.

Fallacy No. 3. Experts know how to change behaviour. Hygiene promotion programmes can't be designed by experts in an office. They have to de designed around the real needs, wants and contexts of the actors themselves, i.e. by taking a consumer-centred approach. On the other hand, hygiene promotion programmes can't be designed by communities themselves; outside expertise is needed.

Fallacy No. 4. A whole variety of hygiene practices should be encouraged. Only a limited number of unhygienic practices are likely to be responsible for most diarrhoeal episodes. Since behaviour change is difficult, efforts should not be diluted by targeting too many practises.

Fallacy No. 5. Hygiene promotion is a cheap add-on to water programmesSerious efforts to change behaviour require serious investment and professional skill.  Hygiene promotion needs careful planning and the best solutions may, or may not, dovetail well with water and sanitation activities.

This fact sheet concerns some new approaches to hygiene promotion that have been developed and applied in programmes around the world. The references and further reading at the end provide more detail.

Building on field experience in Africa and Asia, researchers associated with WELL have developed a new approach, called hygiene promotion. Instead of beginning in an office, programme design begins in the community, finding out what people know, do and want. The approach works well in a participatory, village-by-village manner. However, it is most useful and cost-effective on a large scale, where the intervention is first developed locally, by participatory research, and then applied across regions or urban centres.

Lessons from Marketing and Private Industry

Private Industry is very successful at changing behaviour, its very existence 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 been the basis of the Global Public-Private Partnership for Handwashing. Several country programmes are underway and the successful experiences have now been collated into the Handwashing Handbook (Scott et al, 2005), a practical guide to handwashing promotion at the national level.  

A principle of the approach is to base handwash promotion programmes on understanding of consumer behaviour. The first stage in the process is to conduct comprehensive formative or ‘consumer’ research (see Fig 1) 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? The answers can then be used to design an appropriately targeted promotion campaign.

Summary of the Key Principles in Hygiene Promotion

1. Target a small number of risk practices.

From the viewpoint of controlling diarrhoeal disease, the priorities for hygiene behaviour change are likely to include hand washing with soap (or a local substitute) after contact with stools, and the safe disposal of adults' and children's stools. (Curtis et al, 2000).

2. Target specific audiences.

These may include mothers, children, older siblings, fathers, opinion leaders or other groups. One needs to identify who is involved in child care, and who influences them or takes decisions for them.

3. Identify the motives for changed behaviour.

Motives often have nothing to do with health; behaviour may be driven by disgust, nurture or status. For example, people may be persuaded to wash their hands so that their neighbours will respect them, so that their hands smell nice or as an act of caring for a child. People often do not know their own motives, so consumer research requires patience and skill.

4. Hygiene messages need to be positive.

People learn best when they laugh and will listen for a long time if they are entertained. Programmes which attempt to frighten their audiences will alienate them. There should therefore be no mention of doctors, death or diarrhoea in hygiene promotion programmes.

5. Identify appropriate channels of communication.

We need to understand how the target audiences communicate. For example, what proportion of each listens to the radio, attends social or religious functions or goes to the cinema? To us traditional and existing channels are easier than setting up new ones, but they can only be used effectively if their nature and capacity to reach people are understood.

6. Decide on a cost-effective mix of channels.

Several channels giving the same messages can reinforce one another. There is always a trade-off between reach, effectiveness and cost. Mass media reach many people cheaply, but their messages are soon forgotten. Face-to-face communication can be highly effective in encouraging behaviour change, but tends to be very expensive per capita.

7. Allocate enough resources

Marketing professionals have a rule of thumb that at least six contacts with the message (home visits, sightings of a poster, etc.) are needed to introduce a new product or practice – and still more to ensure it is sustained.

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

At a minimum, information is required at regular intervals on the outputs (e.g. how many broadcasts, house visits, etc.), and the population coverage achieved (e.g. what proportion of target audiences heard a broadcast?). Finally, indicators of the impact on the target behaviours must be collected.

Links with other activities

Hygiene promotion can be a stand-alone activity or it can figure as a planned part of water, sanitation and diarrhoeal disease programmes. The principal danger of subsuming it into a wider programme is that it usually becomes the poor relation, with a low priority for resource allocation and management time. This is almost inevitable when the main priority is seen as the number of wells or latrines constructed. It may be advisable to create separate but linked programmes, each with its own targets and management arrangements.


·          Cairncross, S., Feachem, R.G. (1993) Environmental health engineering in the tropics: an introductory text. 2nd Edition. John Wiley & Sons. Chichester, New York.

·          Curtis, V., Cousens, S., Mertens, T., Traore, E., Kanki, B., Diallo, I. (1993) Structural observations of hygiene behaviours in Burkina Faso: validity, variability, and utility. Bulletin of the World Health Organisation, 71: 23-32.

·          Curtis, V., Cairncross, S., Yonli, R. (2000) Domestic hygiene and diarrhoea – pinpointing the problem. Tropical Medicine & International Health, 5: 22-32.

·          Curtis, V. (2001) Hygiene: how myths, monsters and mothers-in-law can promote behaviour change. Journal of Infection, 43: 75-79.

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

·          Esrey, S.A., Potash, J.B., Roberts, L., Shiff, C. (1991) Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, Schistosomiasis, and  trachoma. Bulletin of the World Health Organisation, 69: 609-621.

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

·          Global Public-Private Partnership for Handwashing website: http://www.globalhandwashing.org

·          Hygiene Central – the website of the Hygiene Centre at the London School of Hygiene & Tropical Medicine: www.lshtm.ac.uk/dcvbu/hygienecentre

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

·          Luby, S.P., Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W.L., Hoekstra, R.M. (2004) effect of intensive handwashing promotion on childhood diarrhoea in high-risk communities in Pakistan: a randomised-controlled trial. Journal of the American Medical Association, 291: 2547-2554.

·          Scott, B., Curtis, V., Rabie, T. (2003) Protecting children from diarrhoea and acute respiratory infections: the role of handwashing promotion in water and sanitation programmes. SEARO Regional Health Forum, 7: 42-47.

·          Scott, B., Curtis, V., Cardosi, J. (2005) The handwashing handbook: a guide to developing a hygiene promotion programme to increase handwashing with soap. World Bank, Washington (http://www.globalhandwashing.org/Publications/Handwashing_Handbook.pdf).

·          WHO/UNICEF (2004). Meeting the MDG drinking water and sanitation target: a mid-term assessment of progress. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (www.unicef.org/publications/index_23223.html).



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