Module

1.5
1.5 Hygiene

A healthy lifestyle is promoted by good hygiene habits and practices. Clean

water must be used for drinking, preparing and cooking food, washing
hands and body, and washing clothes. A good quality water supply has to
be maintained to meet these requirements. Other good hygiene practices
include good housing, food preservation and household waste disposal.
Education about health care through schools, parents and community
health activities should be encouraged.
Module 1.5 Hygiene

1.5 HYGIENE.................................................................................................................................................1
TRANSMISSION ROUTES......................................................................................................................................2
PERSONAL HYGIENE..........................................................................................................................................2
HAND WASHING...............................................................................................................................................3
Effectiveness.............................................................................................................................................3
The 3 x 3 System.......................................................................................................................................4
How Soap Works.......................................................................................................................................4
DOMESTIC HYGIENE..........................................................................................................................................5
WASTEWATER DISPOSAL.....................................................................................................................................5
WASTE HANDLING ...........................................................................................................................................5
FOOD SAFETY...................................................................................................................................................6
Golden rules for safe food preparation....................................................................................................6
PROGRAM PROMOTION TECHNIQUES.....................................................................................................................7
RESOURCES......................................................................................................................................................8

Transmission Routes
The “F Diagram” (because each word begins with “f”) below identifies how
contamination from faeces can reach someone’s face, via four different routes; fingers,
flies, fields, and fluids. The dotted lines indicate how good hygiene practices break the
transmission routes for pathogens. Notice that there are three spheres of influence which
reduce disease; improved water quality, improved sanitation, and improved hygiene. All
three measures implemented together have a much larger effect than any single one
implemented alone.

Personal Hygiene

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Most people practice personal hygiene to a certain degree. It is often a subject that people
do not want to discuss in public. Good personal hygiene will reduce the incidence of skin
and eye infections and diarrhea. Good personal hygiene includes:
• Hand washing
• Bathing regularly
• Frequent washing of children’s hands and face
• Washing hair
• Cleaning teeth at least once a day
• Keeping nails clean and short
• Frequent washing of clothes and bedding

Ample water is needed on a daily basis to practice all of these hygiene requirements.
Where water is scarce or when too much time is consumed in hauling or treating water,
some hygiene practices will be sacrificed. The easier and less time consuming these
activities are made, the more likely the hygiene practices are to be adopted. There are
some interesting resources that can be used to make hygiene more convenient, such as
tippy taps (see Resources).

Cultural norms must also be considered. Everyone is used to doing things in a certain
way, and people will be reluctant to adopt methods that are too different from what
they’re used to. Local knowledge is essential in developing an appropriate hygiene
program. Some things to consider include:
• Religious traditions or taboos
• Women’s and girls’ privacy requirements (for bathing and latrines)
• Current laundry techniques

Hand Washing
Effectiveness
The hygiene behavior which can have the largest impact is hand washing. Ten studies of
hand washing were included in a review of interventions to prevent diarrhea (Huttly et al.
1997). All reported a positive relation between improved hand washing and diarrheal
prevention, with a median reduction in incidences of diarrhea of 33 percent (range 11-89
percent). The finding that improved hand washing can prevent diarrhea was remarkably
consistent in a variety of settings.

For example, Black et al. (1981) cited reductions of 43 percent in diarrhea among day-
care center children in the United States resulting from a simple hand washing
intervention. In Indonesia, improved hand washing behavior by 65 mothers (who
received soap and explanations of the fecal-oral route of diarrhea transmission) reduced
diarrhea incidence in their children by 89 percent (Wilson et al. 1991). Similarly, hand
washing and hygiene behaviour interventions reduced diarrheal disease by up to 39
percent in rural Thai villages (Pinfold and Horan 1996). Hand washing interventions in
urban Bangladesh reduced dysentery (shigella) by 35 percent and non-dysenteric diarrhea

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by 37 percent among all age groups (Khan 1982). In Myanmar, childhood diarrhea was
reduced by 30 percent in urban households where the mother was given soap and hand
washing education (Han and Hlaing 1989). In more recent studies not included in the
1997 review, soap distribution with hand washing education was associated with a 33
percent decrease in childhood diarrhea in urban Bangladesh (Shahid et al. 1996) and soap
distribution alone was associated with a 27 percent reduction in diarrhea in a refugee
camp in Malawi (Peterson et al. 1998).

The 3 x 3 System
Times and Technique for Correct Hand Washing Behaviour:

Three components of correct technique:

• Wash both hands with water and soap
• Rub hands together at least three times
• Dry hands hygienically

Three critical times:

• Before cooking or preparing food
• Before eating or before feeding children
• After defecating and after changing or cleaning babies

How Soap Works

To understand how soap works, one has to look at a soap molecule composed of carbon,
hydrogen and oxygen. It has a "head" composed of carboxyl that attracts water and a
hydrocarbon "tail" that is hydrophobic (afraid of water) but loves oil and grease.

You may have noticed that when you first step into the shower, water beads on the
surface of your skin. This is because the surface tension of the water prevents it from
reaching and clinging to the skin. When soap is introduced, the hydrophobic end of the
soap molecules tries to get as far as possible from the water, while the water loving end
of the molecule is attracted to the water. The result is a film that breaks the surface
tension of the water allowing it to stick to the skin.

The pores of your skin secrete oils that create a barrier to protect you from the
environment. This layer of grease traps dirt, dust and other matter that makes us "dirty".
With the use of soap, the water can reach your skin. When the oil and grease loving tail of
the molecule comes in contact with the skin, it attaches itself to the oily layer containing
the impurities. Once water is applied to rinse, the water loving head of the molecule
literally pulls the dirty tails off the skin, leaving you squeaky clean.

While soap does not really kill the germs, it does allow the water to more effectively
break the skin – dirt bond. Rinsing the dirt off with water and drying the skin afterwards
are key factors in removing germs from the skin and the transmission path is broken.
http://www.harvestsoaps.com/soap_works.htm (Apr 05)

• Clean water must be used when washing hands

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• If a cloth is used to dry hands (preferable) it must be clean and washed regularly,
otherwise air drying is preferable
• If soap is not available or affordable, rubbing mud or dry ash on hands is an
acceptable alternative
• Both hands should be washed (even if only the left is used for anal cleansing)

Domestic Hygiene
The environment around a person’s home and community also greatly affects health.
Waste materials and stagnant water around the home raise the number of insects and
animals, increasing the spread of disease, and allowing pathogens to survive in the
environment longer. Food and anything that is used to prepare it can be significant
sources of fecal contamination. Domestic hygiene includes:
• Disposal of wastewater
• Solid waste handling
• Food safety
• Cleaning cooking utensils and pots and storing them out of contact with insects
and animals
• Sanitation (see Module 1.4)
• Keeping domestic animals in a separate room from people, and out of the kitchen
• Fencing water sources and gardens to keep animals out

Wastewater Disposal
Wastewater from bathing, laundry, food preparation, and cleaning of dishes can cause a
hazard when left to stagnate near homes. Also, excess water that is spilled each time a
well pump is used can quickly add up to create a muddy source of pathogens and may
eventually contaminate the well. Stagnant water creates a breeding site for insects that
carry water-related vector-borne diseases, is a home for water-based diseases such as
parasites, and may contain other pathogens.

There are many options for handling wastewater. A few of these are:
• Construct an apron around wells to divert overflow water to a nearby field for
irrigation
• Dig a “soak-away” (a pit filled with rocks) to allow the wastewater to soak into
the ground
• Teach householders to plant trees or shrubs near their home and pour the
wastewater at the base of those plants
• Construct a basic drainage system within a village
Waste Handling

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The web site listed below discusses the following topics which are important waste
handling considerations:
• Solid waste
• Wastewater disposal techniques
• Refuse storage
• Refuse collection and transport
• Treatment and disposal
• Incineration
• Waste recycling
http://www.who.int/water_sanitation_health/hygiene/emergencies/em2002chap8.pdf (Apr 05)

A king once offered five hundred garments to a disciple of Buddha. The king asked the disciple
what he would do with so many garments. The Disciple replied:
Oh King, many of our brothers are in rags. I am going to distribute the garments among
brothers.
What will you do with the old garments?
We will make bed covers out of them.
What will you do with the old bed covers?
We will make pillowcases out of them.
What will you do with the old pillowcases?
We will make floor covers out of them.
What will you do with the old floor covers?
We will use them for foot towels.
What will you do with the old foot towels?
Your highness, we will tear them into pieces, mix them with mud and use the mud to plaster the
house walls.

What is waste for you is wealth for somebody else.

http://www.cleanindia.org/waste.htm (Apr 05)

Food Safety
Golden rules for safe food preparation
1. Cook raw foods thoroughly.
2. Eat cooked food immediately.
3. Prepare food for only one meal.
4. Avoid contact between raw foods and cooked foods.
5. Choose foods processed for safety.
6. Wash hands repeatedly.
7. Keep all food preparation premises meticulously clean.
8. Use safe water.
9. Be cautious with foods purchased outside.
10. Breast-feed infants and young children.
Source: World Health Organization (1991d)

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Program Promotion Techniques

The following are suggestions to use for promotion of hygiene programs.
• Extensive use of television, radio and newspaper advertisements
• Distribution of posters, banners, brochures and video-audiotapes
• Community activities - hygiene programs in communities through use of generic
campaign materials
• Participation in school hygiene programs
• Participation in markets and fairs

The following is a summary of a study recently undertaken by WaterAid. It describes the

things that were learned from projects that were done a few years ago and what is needed
to ensure that the hygiene behaviours are sustainable.

The prevalence of key hygiene practices essential for good health varies. However, the
key determinants of the sustainable adoption of hygiene behaviour seem to be:
1. Hygiene and sanitation programmes need to be an integral part of water supply
interventions. There is a need to shift emphasis from the provision of facilities
alone to the inclusion of information and education on behaviour and practices.
2. Hygiene promotion programmes should develop skills in collaboration with the
existing local government structures using practical and interactive methods
rather than just passing on information.
3. Children need to be specifically targeted by hygiene promotion programmes. An
ideal approach is to implement hygiene and sanitation programmes in schools.
Government education policies should support these programmes and children not
attending school should also be specifically targeted by community based
organisations.
4. Good hygiene behaviour and its benefits need to be clearly defined to
communities.

Lessons emerging from studies in other countries included:

1. Women influence hygiene in the home. Therefore the formal education of girls is
important.
2. It is necessary during the training in hygiene practices to emphasise the
importance of passing on the information gained to friends, neighbours and other
peers.
3. Government departments should be part of the project structure because
communities identify with them and they are there long after the project agency
has left.
4. An understanding of prevalent taboos and beliefs in a given community and the
design of culturally appropriate facilities and messages is essential.
5. Interventions should preserve the dignity of women and girls.
6. Hygiene promotion messages need to be continually reinforced in order for
changes in behaviour to be long-lasting.
http://www.wateraid.org/site/what_we_do/case_studies/1170.asp (Apr 05)

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Resources
Facts For Life - Excellent book!!
Every year, nearly 11 million children die from preventable causes before reaching their
fifth birthday. Many of these deaths can be avoided if parents and caregivers understand
what to do when illness strikes and how to recognize the danger signs that signal the need
for medical help. Facts for Life presents, in simple language, the most authoritative
information about practical, effective and low-cost ways to protect children's lives and
health. Since it was first published in 1989, Facts for Life has become one of the world's
most popular books, with more than 15 million copies in use in 215 languages in 200
countries. The book is co-published by UNICEF, WHO, UNESCO, UNFPA, UNDP,
UNAIDS, WFP, and the World Bank.
You can access the complete Facts for Life content on this website, as well as the PDF
and text-only versions.
http://www.unicef.org/ffl/ (Apr 05)

This web site has some good material on Practical Hygiene. The topics on this site are:
How to keep drinking water clean; Hand washing; How to keep the community well
water supply clean; How to keep your latrine clean; How to keep your food clean; How
to keep your neighborhood clean.
http://www.rehydrate.org/dd/su36.htm (Apr 05)

Use the “chalk on the ball” game to illustrate how germs are spread. Sprinkle coloured
chalk on a soccer or volley ball. Have a group of children pass it around for a few
minutes. Then have them look at their hands to see that they now have chalk on their
hands. That’s how germs (pathogens) are spread! See the 7th case study on this web site.
http://www.wateraid.org.uk/site/learn_zone/15-18/526.asp# (Apr 05)

This is a good book that may be of use in many places around the world. Where Women
Have No Doctor uses simple English and hundreds of illustrations to help women and
girls from different cultures and educational backgrounds learn how to take care of
themselves. The first comprehensive community-based health book for women, Where
Women Have No Doctor combines medical information with an understanding of how
poverty, discrimination and culture affect women's health and access to health care.
http://www.managingdesire.org/Hesperian/Hesperian.html (Apr 05)

An inspirational vision through the eyes of a West African woman in the year 2020,
highlighting the benefits of a generation of hygiene improvements and raising awareness.
http://eneng.wits.ac.za click on Other, Digital Library, Topics; select World Water Vision
21; select doc14.html (Apr 05)

The web site shows how to make soap. It has very good illustrations that can be used to
teach others how to do it.
http://ourworld.compuserve.com/homepages/paul_norman_3/soapmake.htm (Apr 05)

The International Scientific Forum on Home Hygiene comprises scientists and healthcare
professionals who play an active role in hygiene policy and scientific research. Through

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its international initiatives and activities, the IFH wishes to emphasise the fundamental
role that hygiene plays in preventing infection and disease.
http://www.ifh-homehygiene.org/2003/2mission/2ifh00.asp (Apr 05)

Rehydration Project is a private, non-profit, non-sectarian, international development

group. It aims to work within the health framework of developing countries to help them
achieve and maintain high levels of immunization, improve access to clean water and
safe sanitation, support breastfeeding, promote hygiene education, produce Oral
Rehydration Solution (ORS) and assist in ensuring that sufficient ORS is available. It also
shows these countries how to promote ORS’ effectiveness and how to develop
educational programs to encourage widespread usage. In short: new ways to promote,
produce and provide ORS.

Oral Rehydration Therapy (ORT) consists of drinking a simple solution to replace the
water and salts lost from the body during diarrhoea. The solution, Oral Rehydration Salts
(ORS), can be prepared by adding water to a packet of glucose and salts costing about 10
cents, or it can be made from commonly available household ingredients, such as salt and
sugar (or a cereal such as rice) mixed with water.

Oral rehydration is one of the most cost-effective of all medical technologies. The total
cost (including staff salaries and other overhead) for treating a child with ORT at a health
facility is about US$1. If mothers themselves prepare a solution from ingredients
normally available in the home, the cost is only a few cents. Drugs are usually required
for no more than 10 percent of children treated at health facilities for diarrhoea.

THE primary source of information on diarrhoea prevention and Oral Rehydration

Solution. Excellent!
http://www.rehydrate.org/dd/ (Apr 05)

How to make a tippy tap from a plastic jug - it tips out a small amount of water that
children use when they are washing their hands.
http://www.hdra.org.uk/factsheets/tippy_tap.htm (Apr 05)

Another site with a tippy tap

http://education.otago.ac.nz/NZLNet/WaraBlongLife/tippytap.pdf (Apr 05)

This is a study on hand washing and recommending the use of a tippy tap and pretty
corner. It has steps that the community promoter should do.
http://www.unu.edu/unupress/food/8F151e/8F151E0e.htm (Apr 05)

This is another good newletter on hand washing and the use of a tippy tap.
http://myindia.net/pdf/dd54.pdf (Apr 05)

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These pages have some good education material

http://education.otago.ac.nz/NZLNet/WaraBlongLife/resources.html (Apr 05)
http://www.globalhandwashing.org/ (Apr 05)

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