Analysis of different communication channels for promoting hygiene behaviour.

A hygiene intervention study reduced diarrhoeal disease transmission in rural northeast Thailand by promoting hand-washing and dish-washing behaviour. Most of the target audience did not recognize a connection between these behaviours and diarrhoeal disease, and therefore a social marketing approach was used to develop a campaign promoting behaviours through a variety of communication channels keeping messages simple and in terms understood by the community. Overall, there was a strong correlation between the number of communication channels remembered by respondents and their knowledge score, with passive channels of printed media such as stickers, posters and leaflets associated with significantly higher scores than other channels. However, the same did not hold true for improvement in actual behaviour and only 'school children' were associated with significantly less fingertip contamination. In-depth interviews with conformers and non-conformers suggested that although most knew the intervention messages well enough, the importance they attached to them differed markedly. Thus dissemination of message knowledge was not consistent with the process of dissemination of actual practice. Where a strong sense of community spirit existed, friends, relatives and neighbours were more likely to discuss intervention activities with each other.

Measuring the effect of a hygiene behaviour intervention by indicators of behaviour and diarrhoeal disease.

A social marketing approach used both qualitative and quantitative methods to develop a hygiene behaviour intervention in rural north-east Thailand. Behaviours were preselected from a previous study and the intervention was designed to promote hand washing, especially before feeding a baby, cooking, eating, and after defaecation or cleaning a baby's bottom, and dish washing immediately after eating. A bacteriological indicator (enumerating faecal streptococci using a finger impression technique) was developed to measure changes in hand washing behaviour and observation (spot checks) of dirty dishes to indicate dish washing practice. There was a significant improvement in both behaviours and a significant reduction in diarrhoeal disease as a result of the intervention. Furthermore, both indicators were retrospectively found to be positively related to diarrhoeal disease incidence. However, receiving and being able to recall the intervention messages was not necessarily sufficient to ensure behaviour change, as some adults found it difficult to change old habits. Villages showing the greatest improvement tended to have a stronger sense of community than others and to have more people actively involved in the intervention.

Microbiological methods for assessing handwashing practice in hygiene behaviour studies.

Personal hygiene, especially handwashing, is frequently mentioned as an important aspect of diarrhoeal disease prevention in water and sanitation programmes. Handwashing practice is difficult to assess but the microbiological analysis of hands shows promise as an indicator of this behaviour. Most methods for isolating bacteria from the hands have been developed for use in hospitals in order to investigate the spread of nosocomial infections. However, reliable and inexpensive methods which need only limited expertise are needed for use in developing countries where diarrhoeal diseases remain a major health risk. Techniques for sampling hands and bacteriological analysis methods are discussed with special emphasis on practical considerations for conducting tests in developing countries. Several studies have used these methods successfully and have investigated hygiene behaviour and how living conditions affect behaviour and the role of hands in diarrhoeal disease transmission. We recommend the use of impression plates for isolating faecal indicator bacteria from the hands and also recommend faecal streptococci as an indicator of faecal contamination.

Seasonal effects on the reported incidence of acute diarrhoeal disease in northeast Thailand.

This paper examines the seasonal variation in the reported incidence of acute diarrhoea for selected areas in the northeast of Thailand. Charts are presented which show rainfall, temperature and reported incidence of acute diarrhoea for the period 1982 to 1987. Incidence of diarrhoea appears to be inversely related to a sharp decrease in temperature around January each year. Although rainfall does not appear to have a direct effect on the relative incidence of acute diarrhoea, there is always a consistent reduction during July or August, after the rains have begun. Seasonal changes in climate may be indirectly related to other factors which have an important bearing on diarrhoeal disease. Rainwater collection is an important water source in this region and the affect this has on water use is discussed in relation to faeco-oral disease transmission.

PIP: Researchers compared data on acute diarrhea incidence with data on rainfall and temperature of 10 provinces and 15 districts of Khon Kaen province in northeast Thailand to determine the link between seasonal weather patterns and reported incidence of acute diarrhea. The relative incidence of diarrhea decreased with age in the winter while it increased with age in the hot season and early in the rainy season. Indeed reported incidence of diarrhea peaked in January for children 2 years old. The researchers suggested that rotavirus was the leading causative agent in this age group since it is common in cooler months and in children 2 years old. Another peak occurred in April-June when temperatures are high and early in the rainy season. This peak involved mainly adults. The researchers believed enterotoxigenic Escherichia coli, Campylobacter jejuni, and Shigella were the leading causative agents. The researchers posed a possible explanation for this April-June peak. In the beginning of the wet season, households changed their water source from groundwater to rainwater and began to use it differently. Further, they often stored water separately from rainjars. It was more likely that this water was more contaminated than stored rainwater or groundwater. In addition, fecal bacteria transmitted by food preparation and utensil handling and the rising humidity fostered its growth. These events may have accounted for the increased incidence of diarrhea in the early rainy season. A steep reduction in diarrhea incidence occurred around the middle of the wet season (July and August). Research has shown that increased water quantity may be better in reducing diarrhea incidence than only improving water quality. Furthermore, it also demonstrated that bacteriological quality of water stored in rainjars was better than water from shallow wells.

Faecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water supply and sanitation activities on faeco-oral disease transmission. I. A case study in rural north-east Thailand.

Most villagers in north-east Thailand carry water to their homes and store it in separate containers depending on its subsequent use. In one village, information on water use was collated with the bacteriological quality of stored water, water sources and fingertip-rinses. Stored water quality was a function of water-related activities rather than quality at source (P less than 0.0001). Specifically water used for toilet, washing dishes and cooking-related activities was much more contaminated with faecal bacteria than that used for drinking and cooking. Salmonella spp. was significantly more common in water used for washing dishes than drinking (P less than 0.05). Escherichia coli contamination of fingertip-rinses was strongly associated with the individual's activity prior to testing (P less than 0.0001); child care, food and water-related activities produced much higher levels of fingertip contamination than others. Dirty utensils used for cooking and eating were usually left to soak and faecal bacterial growth occurred in this grossly contaminated soak-water. Cross-contamination via water handling was the main mechanism of stored water pollution. These results were used to develop a hygiene intervention study presented in a companion paper.

Faecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water supply and sanitation activities on faeco-oral disease transmission. II. A hygiene intervention study in rural north-east Thailand.

An intervention study was developed from risk-factors associated with faeco-oral transmission, based on the levels of contamination in stored water and fingertip-rinses from households in rural north-east Thailand. This was designed to improve: (a) handwashing, particularly before cooking/eating and after defecation: (b) washing dishes immediately after use. Verbal messages were administered to two intervention groups, one also received a plastic container with a tap to assist these activities. Indicators of compliance were the direct observation of soaking dishes and the presence of faecal streptococci from fingertip-rinses; the main outcome indicator was Escherichia coli contamination of stored water. The intervention group receiving the container was significantly better than the control for indicators of compliance (P less than 0.001 and P less than 0.01) and its stored water was significantly less contaminated (P less than 0.001). There was no significant improvement to the other intervention group, although some features of the intervention had clearly been made available to the control group. Humidity was significantly correlated with fingertip contamination (r = 0.2; P less than 0.001) and with the peak of reported diarrhoea around the beginning of the rainy season.

The faecal coliform fingertip count: a potential method for evaluating the effectiveness of low cost water supply and sanitation initiatives.

A rapid and simple procedure for the enumeration of faecal coliform bacteria present on the fingertips is described. The distribution of individual faecal coliform fingertip counts within households has been compared with a number of variables related to the availability of water supply and sanitation facilities. This showed a strong association between the fingertip count and the possession of in-house water connections. It is proposed that this test might provide a reliable indication of the effectiveness of certain public health interventions.