Faecal-oral paradigm: part 4 - Hygiene behavior in a Sub-Saharan context.

In addition to part 3 of this mini-series which presented a range of arguments as to the most effective methods to restrict faecal-oral transmission, this short blog focuses on a paper which provides an eye opening example of observed hygiene behaviors from North East Botswana which forms a part of Sub-Saharan Africa (where 700 million people are without access to improved sanitation), reiterating the importance of education alongside other approaches to tackle faecal-oral transmission.

A study by Kaltenthaler and Drasar (1996) focused on the relationship between hygiene behavior and diarrhoeal diseases  for young children. Although the investigation was relatively narrow in scope, considering only two villages in North East Botswana over a one year period, the study raises awareness to some interesting themes concerning hygiene and faecal-oral transmission. Similar to findings from Ethiopia (Tucker et al., 2014),  water sources were chosen not based on whether it was improved and protected but instead on factors such as distance from home and water taste. One of the findings that surprised me most is that diarrhea was often not considered to be caused by faecal-oral transmission but thought instead to be caused by a sunken fontanelle, child bewitchment, cold weather and bad food. Prevention and treatment was also found to differ from that provided by health services and included visiting a traditional healer. Furthermore, understanding of what is contaminated or dirty differs somewhat from bacteriological concepts. For instance cow dung and infant faeces were reportedly not traditionally considered contaminated, whereas adult faeces and menstrual blood were considered very dirty. It is clear that these findings cannot be generalised, specifically because of the small study size. Nonetheless, the study supports the arguments of Esrey et al. 1991 (click here), highlighting how existing beliefs have the capacity to undermine improved hygiene behavior and therefore should be considered when wider improvements to water and sanitation are being made. Even if the best water and sanitation systems are installed, they will be wasted if their usefulness and importance are not fully understood or trusted.