Author: Valerie Curtis,
reviewed and updated by Lucy Smith, July
Quality assurance: Sandy Cairncross
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.
& Cairncross, 2003I
pit latrine, including for the
disposal of children's faeces
can reduce diarrhoea incidence by 36% or more.
et al, 1991; Fewtrell et al,
the quality of water at the
household level can reduce risk
of diarrhoea by 35%
et al, 2005
Promotion: the Scale of the Problem
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).
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:
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.
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,
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.
Fallacies about Hygiene Promotion
No. 1. Behaviour change is easy. Getting
people to change the habits of a lifetime is
difficult, takes time and requires resources and
No. 2. Knowledge change=behaviour change.
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.
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.
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.
No. 5. Hygiene promotion is a cheap add-on
to water programmes. Serious
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.
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.
from Marketing and Private Industry
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
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.
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
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.
Allocate enough resources
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
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.
S., Feachem, R.G. (1993) Environmental health
engineering in the tropics: an introductory text. 2nd
Edition. John Wiley & Sons. Chichester, New
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:
V., Cairncross, S., Yonli, R. (2000) Domestic
hygiene and diarrhoea – pinpointing the problem. Tropical
Medicine & International Health, 5:
V. (2001) Hygiene: how myths, monsters and
mothers-in-law can promote behaviour change. Journal
of Infection, 43:
V., Cairncross, S. (2003) Effect of washing hands
with soap on diarrhoea risk in the community: a
systematic review. Lancet
Infectious Diseases, 3:
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.
the World Health Organisation, 69:
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
Infectious Diseases, 5:
Public-Private Partnership for Handwashing website: http://www.globalhandwashing.org
Central – the website of the Hygiene Centre at the
London School of Hygiene & Tropical Medicine: www.lshtm.ac.uk/dcvbu/hygienecentre
B.P. (1990) Health education interventions in
developing countries: a methodological review of
published articles. International Journal of Epidemiology, 19: 788-794.
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:
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:
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).
the MDG drinking water and sanitation target: a
mid-term assessment of progress. WHO/UNICEF
Joint Monitoring Programme for Water Supply and
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