Evidence of behaviour change following a hygiene promotion programme in Burkina Faso.

OBJECTIVES: To determine whether a large, 3-year hygiene promotion programme in Bobo-Dioulasso, Burkina Faso, was effective in changing behaviours associated with the spread of diarrhoeal diseases. The programme was tailored to local customs, targeted specific types of behaviour, built on existing motivation for hygiene, and used locally appropriate channels of communication. METHODS: Two population surveys recorded the coverage of the programme among target audiences (mothers of children aged 0-35 months). Four surveys were carried out: three prior to the programme and one in 1998 (after the programme had been running for 3 years), using structured observation of hygiene behaviours in the participants' homes to document changes in target behaviours. FINDINGS: After the programme had run for 3 years, three-quarters of the mothers targeted had had contact with programme activities. Half could cite the two main messages of the programme correctly. Although the safe disposal of children's stools changed little between 1995 and 1998 (80% pre-intervention, 84% post-intervention), hand-washing with soap after cleaning a child's bottom rose from 13% to 31%. The proportion of mothers who washed their hands with soap after using the latrine increased from 1% to 17%. CONCLUSION: Hygiene promotion programmes can change behaviour and are more likely to be effective if they are built on local research and use locally appropriate channels of communication repeatedly and for an extended time.

Bednets and malaria.

PIP: Studies across Africa have shown that insecticide-treated materials (ITMs) such as bednets can substantially reduce levels of child mortality through the prevention of malaria. However, while the results of efficacy trials may dictate the need to use ITMs, people in malaria-endemic areas may not recognize and comply with the need. If one wishes to get people to use health technology such as insecticide-impregnated bednets, one must learn about the end-users through clear, simple, formative research, identifying their habits, needs, and wants. Whichever strategy is employed to get ITMs to people in need, the end-users must be committed to obtaining them, caring for them, and using them. All populations in sub-Saharan Africa go to considerable lengths to avoid being bitten by mosquitoes, and see mosquitoes as nuisances rather than as the vectors of a potentially deadly disease. These populations therefore want bednets more to counter mosquitoes as a nuisance than for use as a health technology. In accordance with the population's desires, the authors in Bobo-Dioulasso, Burkina Faso, no longer stress the health benefits of using insecticide-impregnated bednets. They instead promote ITMs as devices capable of giving families peace from mosquitoes and their bites. To repel not only Anopheles gambiae, the vector of malaria-causing parasites, but also Culex, the main nuisance biter in the area, a higher dose of insecticide is now being used to ensure the broad-spectrum repulsion of mosquitoes by ITM users.^ieng

Hygiene promotion in Burkina Faso.

PIP: Successful hygiene promotion programs in developing countries require identification of local risk practices and messages most likely to have a real impact on disease incidence. This process was applied in a diarrhea prevention program in Bobo-Dioulasso, Burkina Faso. Field workers observed and recorded events such as child defecation and met with mothers to develop feasible alternative practices. Key was prevention of feces from getting into the environment, either through better stool control or adequate hand washing after stool contact, preferably with soap. It was determined that the most effective means for stopping fecal material from getting into the child's environment is to ensure that feces are disposed of safely and to ensure that hands that have come into contact with feces are thoroughly washed. Prevention of fecal materials from entering the domestic environment substantially reduces the risk of secondary transmission through uncovered food, unwashed plates. Interventions that make water more accessible facilitate hand washing and other domestic hygiene measures. The need for costly fly control measures can be reduced by steps to abolish breeding sites in animal dung.^ieng

Dirt and diarrhoea: formative research in hygiene promotion programmes.

Investment in the promotion of better hygiene for the prevention of diarrhoeal diseases and as a component of water and sanitation programmes is increasing. Before designing programmes capable of sustainably modifying hygiene behaviour in large populations, valid answers to a number of basic questions concerning the site and the intended beneficiaries have to be obtained. Such questions include 'what practices favour the transmission of enteric pathogens?', 'what advantages will be perceived by those who adopt safe practices?' and 'what channels of communication are currently employed by the target population?' A study of hygiene and diarrhoea in Bobo-Dioulasso, Burkina Faso, used a mixture of methods to address such questions. This paper draws on that experience to propose a plan of preliminary research using a variety of techniques which could be implemented over a period of a few months by planners of hygiene promotion programmes. The techniques discussed include structured observation, focus group discussions and behavioural trials. Modest investment in such systematic formative research with clear and limited goals is likely to be repaid many times over in the increased effectiveness of hygiene promotion programmes.

PIP: Before designing programs to sustain hygiene behavior modification in large populations, some basic questions must be answered regarding the site and the intended beneficiaries. For example, planners need to know which practices foster the transmission of enteric pathogens, which advantages will be perceived by those who adopt safe practices, and which channels of communication are currently used by the target population. A study of hygiene and diarrhea in Bobo-Dioulasso, Burkina Faso, used a mix of methods to explore such questions. The authors refer to that experience in proposing a plan of preliminary research using a variety of techniques which could be implemented over a period of a few months by planners of hygiene promotion programs. The techniques discussed include structured observation, focus group discussions, and behavioral trials. Modest investment in such systematic formative research should pay off through the increased effectiveness of hygiene promotion programs.

Reactivity and repeatability of hygiene behaviour: structured observations from Burkina Faso.

If interventions promoting improved hygiene behaviour to prevent childhood diarrhoea are to be implemented and evaluated, valid methods for measuring this behaviour will be required. This paper presents findings from a study to investigate the use of structured observations to measure hygiene behaviour in Burkina Faso. Two hundred mothers with young children (2-36 months) were observed on several occasions, with particular attention focused on events/behaviour surrounding defaecation. Child defaecation occurred most often in a potty (67% of occasions). Stools were most often disposed of into a latrine (79%). Following defaecation the child's bottom was usually rinsed using water alone with a bare hand (76%). Subsequent hand washing by the mother/caretaker was much rarer (29%). None of these behaviours appeared "reactive" to the presence of the observer. Less common behaviors showed some evidence of reactivity. The frequency of child defaecation in the yard increased over the course of three observations (5% to 16%; P = 0.01) and the proportion of occasions on which the child was observed to be cleaned after defaecation declined (95% to 85%; P = 0.01). Mothers usually took with them to the latrine a water recipient (91%). Hand washing after leaving the latrine was observed on 30% of occasions. This proportion declined from 36% to 22% over three observations (P = 0.05). Defaecation by older siblings (aged 3-5 years) was usually into a potty (48%) or directly in a latrine (30%). There was no evidence that this behaviour was reactive. The repeatability of behaviours at the individual level was generally low. The site of index child defaecation (kappa = 0.27), how the child's bottom was cleaned (kappa = -0.01) and whether the caretaker washed her hands afterwards (kappa = 0.26) all showed low repeatability. The method of stool disposal was more repeatable (kappa = 0.73). Hand washing by mothers after using the latrine showed moderate repeatability (kappa = 0.40). Older sibling's defaecation behavior had excellent repeatability (kappa = 0.90). Our findings suggest that, in studies which aim to measure behaviour at the population level, structured observations may provide a useful tool. Studies which investigate links between hygiene behaviour and diarrhoea incidence at the individual level will require repeated observations of mothers and children since measuring behaviour during a single observation will lead to misclassification of exposure status, resulting in bias which could mask any underlying association. This is likely to be very costly.

Anaemia among women of reproductive age in Burkina Faso.

The control of anaemia among women of reproductive age (15-49 years) is one of the priorities of the Safe Motherhood initiative. This article presents the results of a study that was carried out to provide some of the information needed for an effective and sustainable programme to control anaemia in women of this age group in Burkina Faso.

PIP: The control of anemia in women of childbearing age is essential to prevent low birth weight and perinatal and maternal mortality. To help identify appropriate intervention strategies for the control of iron deficiency anemia in Burkina Faso, cluster sampling of women 15-49 years of age was conducted in Bobo-Dioulasso. Of the 251 women selected, 56 were pregnant and 123 were breast feeding. Chronic nutritional deficiency (defined as a body mass index under 19 kg/m2) was present in 18% of women. The overall prevalence of anemia was 58.6% (71.4% among pregnant women, 64.2% among breast-feeding women, and 38.9% among non-pregnant/non-lactating women). Although health service utilization was high (91% for prenatal care and 72% for delivery) in this sample, only 11% had taken iron tablets. Ignorance about the benefits of iron supplements, the black color of feces associated with use of the tablets, and the tablets' unpleasant odor were the main reasons for non-compliance. When health workers addressed these concerns, women were compliant. Examination of conjunctival pallor had low sensitivity (16%) as a screening mechanism for anemia, while the portable hemoglobinometer was both acceptable and accurate. Recommended are programs to prevent malaria and malnutrition--the two main causes of anemia in Burkina Faso.

Speech production and cognitive deficits on Mt. Everest.

Deficits in speech motor control and in the comprehension of syntax were observed as five members of the 1993 American Sagarmatha Expedition ascended Mt. Everest. We analyzed speech recordings and cognitive test scores of the climbers at different altitudes. The mean "voice onset time" interval that differentiates "voiced" stop consonants from their "unvoiced" counterparts (e.g., a [b] from a [p]) decreased from 24.0 ms at Base Camp to 5.4 ms at Camp Three. The time needed to comprehend simple spoken English sentences increased by 50% at higher altitudes, and was correlated with speech motor deterioration. This pattern of deficits is similar to that noted for Parkinson's disease and may reflect disruption of subcortical pathways to prefrontal cortex. Similar procedures could be used to remotely assess cognitive impairments caused by hypoxia, carbon monoxide or alcohol intoxication, or drugs, in order to monitor crew behavior in aeronautics and spaceflight operations, or to evaluate the treatment of neurodegenerative diseases such as Parkinson's disease.

Potties, pits and pipes: explaining hygiene behaviour in Burkina Faso.

Stool disposal practices have been shown to be associated with childhood diarrhoea. However, efforts to promote improved hygiene behaviour are hampered by a lack of understanding of what determines those behaviours. Data from 2793 household interviews with mothers of children from the town of Bobo-Dioulasso in Burkina Faso were analyzed to examine what differentiated mothers who reported using safer stool disposal practices from those who did not. Three 'outcomes' were considered: where the child was reported to defaecate; where the mother reported disposing of the child stools; and whether excreta were observed in the compound. Regression models were developed to identify those factors with the strongest independent associations with the outcomes. There was a consistent association between the source of water and the outcomes. Mothers with access to a tap in the yard reported using safe hygiene practices three times more often than mothers using wells outside the compound and twice as often as mothers who used public standpipes or wells within the yard. The source of water showed a similar pattern of association with observations of faecal matter in the environment. Improved sources of water may contribute to safer stool hygiene by reducing the time spent on water collection or by encouraging mothers to conform to higher standards of hygiene. Other factors which played a role in predicting the hygiene behaviour of mothers were the husbands' occupation, the number of health education sessions that she had attended, her zone of residence and family ownership of certain valuable objects. These factors are likely to be related and to be, to some extent, proxies for the real determinants of her behaviour. A model of the cultural, psycho-social and infrastructural proximate determinants of hygiene behaviour is proposed. Data from focus group discussions suggested that the main purpose of hygienic behaviour is to conform to existing norms of social etiquette. Trials of interventions based on changing such norms are needed to test whether this is an effective means of promoting of safer hygiene practices.

Child defecation behaviour, stool disposal practices, and childhood diarrhoea in Burkina Faso: results from a case-control study.

OBJECTIVE: To investigate the association between where young children defecate, where stools are disposed of, and the presence of human stools on the ground in the compound and the rate of hospital admission with diarrhoea. DESIGN: This was a case-control study with two control groups. SETTING: The study took place in Bobo-Dioulasso, the second city of Burkina Faso in West Africa. PARTICIPANTS: Three groups of children aged 36 months and under, and living in Bobo-Dioulasso were studied. Cases were 757 children admitted to hospital with symptoms of diarrhoea or dysentery. The first control group comprised 757 neighbourhood control children approximately matched on age and date of recruitment, and the second, 631 children admitted to the same hospital without symptoms of diarrhoea or dysentery. MAIN RESULTS: There was no evidence of any association between where the child was reported to defecate and hospital admission with diarrhoea or dysentery (odds ratio = 1.10; 95% confidence interval (CI) 0.78, 1.57, cases v neighbourhood controls; odds ratio = 0.84; 95% CI 0.60, 1.18, cases v hospital controls). There was evidence of an association between where the mother reported disposing of the child's stools and hospital admission with diarrhoea or dysentery (odds ratio = 1.50; 95% CI 1.09, 2.06, cases v neighbourhood controls; odds ratio = 1.31; 95% CI 0.96, 1.79, cases v hospital controls). Human stools were more frequently observed in the yards of cases than controls (odds ratio = 1.38; 95% CI 0.98, 1.95, cases compared with neighbourhood controls; odds ratio = 1.33; 95% CI 0.96, 1.84, cases compared with hospital controls). CONCLUSIONS: The findings suggest that it is not where the child defecates that matters but how the mother then deals with the child's stools.

Structured observations of hygiene behaviours in Burkina Faso: validity, variability, and utility.

The use of observation techniques has been promoted for the study of hygiene practices; however, questions still remain about the validity and repeatability of such techniques. In this article we compare data on hygiene behaviours obtained from questionnaires with data obtained using a structured observation approach and examine the repeatability of structured observations of behaviours and spot observations of environmental conditions. Poor agreement between questionnaire responses and observations was found for child defecation and stool disposal practices (kappa statistic: 0.25 and 0.28, respectively). There was evidence of over-reporting of "good" behaviours (P < 0.0001). Repeated observations of child defecation and stool disposal behaviours showed better agreement (kappa statistic: 0.76 and 0.62, respectively) based on small sample sizes. These findings suggest that our questionnaire data are less valid than data obtained by direct observation. However, different approaches to questioning may be less prone to over-reporting of "good" behaviours than our approach. Further research into the validity of different forms of question is warranted. Behaviours and conditions related to hygiene vary. Observations may be useful in determining the frequency of different behaviours/conditions in the community. However, individual practices may be too variable to assign individuals to exposed and non-exposed groups for the purpose of identifying links with health outcomes. Further studies on the variability of behaviours and the repeatability of observations are therefore needed.

PIP: The measurement of health behavior has included point-in-time structured questionnaires and structured observation. The correlation between these 2 approaches for assessing hygiene practices has not been found to be high. In this study, questionnaire responses, direct observations of behavior, repeated observations of hygiene behavior, and repeated observations of environmental conditions related to hygiene are compared. The unweighted kappa statistic was used to assess the degree of agreement between questionnaire responses and direct observation, and between repeated observations. McNemar's test and chi-square tests were used for examining general associations and trends. The case control study of childhood diarrhea was conducted in Bobo-Dioulasso, Burkina Faso under between January 15, 1990 and March 31, 1991, among a sample of children under 36 months old who had been admitted to Sanou Souro Hospital. Each child upon discharge was visited at home and matched to a control in the same neighborhood. A precoded data collection form was used during the observation to record behaviors. There were 10 households that were observed on 6 separate occasions out of the 57 (10%) households with repeat observations. Home interviews were conducted for 2775 children. 548 households were involved in direct observation. The findings revealed that agreement between questionnaire responses and observations on child defecation and stool disposal practices were very poor when chance agreement was taken into account. "Good practices" were overreported. Repeated observations were in greater agreement. The results were consistent with the hypothesis that questionnaire responses are less valid. One caveat was the way the question was posed; different results might have been achieved had the question been: "What happened the last time the child defecated?" Another difficulty is the assumption that behaviors are habitual as a justification for an initial observation. The suggestion is that hygiene behaviors are variable and the degree of consistency may vary substantially; an example is given to show the consequences of this variability. Measurement may be useful to gauge a general level of incidence, but not behavioral change or assignment into risk or nonrisk groups. Further research is warranted.

Prolonged breast-feeding: no association with increased risk of clinical malnutrition in young children in Burkina Faso.

Reported are our findings from a case-control study of the association between prolonged breast-feeding and clinical malnutrition in an urban setting in West Africa. The cases were children aged 12-36 months who had been hospitalized with a diagnosis of clinical malnutrition. Children of a similar age who lived in neighbouring courtyards were recruited as controls. For 152 case-control pairs in which both children were receiving solid foods, non-breast-feeding was associated with an increased risk of clinical malnutrition (crude odds ratio = 2.37; 95% confidence interval = 1.24, 4.55). This association remained statistically significant after controlling for various potentially confounding variables (P = 0.03). Our findings suggest that either prolonged breast-feeding may offer substantial protection against clinical malnutrition in the study population or malnutrition leads mothers to stop breast-feeding. These results are inconsistent with those of a number of workers who have reported that prolonged breast-feeding is associated with an increased risk of malnutrition. This inconsistency might have arisen because of differences in the definition of malnutrition used or because of variations in the quantity and quality of weaning foods available in different settings. We found no evidence to support the hypothesis that prolonged breast-feeding may be detrimental to children.

PIP: This case control study includes all children aged 12-36 months admitted to the pediatric unit of Sanou Souro Hospital for clinical malnutrition in Bobo-Biolasso, Burkina Faso in 1990 and early 1991. Cases numbered 273 persons, and matched controls numbered 173. 75% of cases have a diagnosis of marasmus, 10% have a diagnosis of kwashiorkor, and 15% have a diagnosis of marasmic kwashiorkor, Mortality includes 50% (14 cases) of the kwashiorkor cases and 30% of each of the other types of malnutrition. All cases show a poor anthropometric status (-4.2 among marasmus cases, -2.75 among kwashiorkor cases, and -3.80 among marasmic kwashiorkor cases). Only 2% show clinical malnutrition. The primary diagnoses are for diarrhea (78%), vomiting (46%), hepatomegaly (25%), dyspnoea (14%). and lymphadenopathy (14%). 35% are aged 12-17 months, 38% are aged 18-23 months, 18% are aged 24-29 months, and 9% are aged 30-36 months. 53% are male. 72% are in receipt of home follow-up visits. Of the 77 not followed up, 30 died. Cases and controls are grouped by feeding patterns (solid foods without breast milk, solid foods and breast milk and without or without porridge, and no solid foods). More malnutrition cases occur among children in the group with no solid food (11 with breast milk and/or other milk or porridge and 7 with porridge only). Those eating solid food with breast milk have a reduced odds of malnutrition. The case-control analysis indicates that more malnutrition occurs among those receiving breast milk or other milk. But with controls for age and supplementation the results indicate that children not receiving breast milk are twice as likely to suffer clinical malnutrition (odds ratio of 2.37), and the occurrence varies with age. Logistic regressions with control for confounding factors indicate that children without breast milk have three times the risk of malnutrition. Prolonged breast feeding and solid food supplements are associated with a 70% reduction in the rate of clinical malnutrition. Caution is urged in accepting wholly the findings due to the potential for reverse causality.

Structured observations of hygiene behaviours in Burkina Faso: validity, variability, and utility

The use of observation techniques has been promoted for the study of hygiene practices; however, questions still remain about the validity and repeatability of such techniques. In this article we compare data on hygiene behaviours obtained from questionnaires with data obtained using a structured observation approach and examine the repeatability of structured observations of behaviours and spot observations of environmental conditions. Poor agreement between questionnaire responses and observations was found for child defecation and stool disposal practices (kappa statistic: 0.25 and 0.28, respectively). There was evidence of over-reporting of "good" behaviours (P < 0.0001). Repeated observations of child defecation and stool disposal behaviours showed better agreement (kappa statistic: 0.76 and 0.62, respectively) based on small sample sizes. These findings suggest that our questionnaire data are less valid than data obtained by direct observation. However, different approaches to questioning may be less prone to over-reporting of "good" behaviours than our approach. Further research into the validity of different forms of question is warranted. Behaviours and conditions related to hygiene vary. Observations may be useful in determining the frequency of different behaviours/conditions in the community. However, individual practices may be too variable to assign individuals to exposed and non-exposed groups for the purpose of identifying links with health outcomes. Further studies on the variability of behaviours and the repeatability of observations are therefore needed

Communication as group process media of aircrew performance.

This study of group process was motivated by a high-fidelity flight simulator project in which aircrew performance was found to be better when the crew had recently flown together. Considering recent operating experience as a group-level input factor, aspects of the communication process between crewmembers (Captain and First Officer), were explored as a possible mediator to performance. Communication patterns were defined by a speech act typology adapted for the flightdeck setting and distinguished crews that had previously flown together (FT) from those that had not flown together (NFT). A more open communication channel with respect to information exchange and validation and greater First Officer participation in task-related topics was shown by FT crews while NFT crews engaged in more non-task discourse, a speech mode less structured by roles and probably serving a more interpersonal function. Relationships between the speech categories themselves, representing linguistic, and role-related interdependencies provide guidelines for interpreting the primary findings.

Communication indices of crew coordination.

The relationship between communication patterns and performance in 10 two-person flightcrews is explored with the aim of identifying speech variations which differentiate low- and high-error full mission simulator flights. Verbal data, transcribed from the videotaped performances, are treated as interactive sequences of speech events in which statements spoken by one crewmember are considered within the context of the other crewmember's prior and subsequent speech. Specific speech patterns characterized each crew, but the overriding findings included: a) marked homogeneity of patterns characterizing low-error crews, interpreted as the adoption of a standard form of communicating, and b) heterogeneity of patterns characterizing high-error crews, interpreted as the relative absence of a conventionalized form. Because conventions are regularities which confirm the expectations of those involved, predictability of crewmember behavior should be greater when standard conventions are followed. We conclude that such a practice can facilitate the coordination process and enhance crew performance.