1. Hygiene, Sanitation and Water:
in diarrhoea prevention
Val Curtis
London School of Hygiene
& Tropical Medicine

2. DISCLOSURE STATEMENT
Speaker: Val Curtis
Dr. Val Curtis has disclosed the following financial relationships. Any
real or apparent conflicts of interest related to the content of this
presentation have been resolved.
Affiliation / Financial Interest Organization
Research contract Unilever, Rekitt-Benkeser
GoJo Industries, Colgate-Palmolive,
Consultancies
Kimberly-Clarke, Unilever

3. WHY?
WHAT?
HOW?

4. Why WASH?

5. Formica polyctena. Holldobler and Wilson, 1990

6. Plausibility Microbiology Observational RCT
Hygiene
Sanitation
Water

8. Fluids
Fields
New
Faeces Foods
Host
Flies
Fingers

9. Fluids
Fields
New
Faeces Foods
Host
Flies
Fingers

10. Fluids
Fields
New
Faeces Foods
Host
Flies
Fingers

11. Fluids
Fields
New
Faeces Foods
Host
Flies
Fingers

12. Fluids
Fields
New
Faeces Foods
Host
Flies
Fingers

13. Fluids
Fields
New
Faeces Foods
Host
Flies
Fingers

14. Fluids
Fields
New
Faeces Foods
Host
Flies
Fingers

15. Plausibility Microbiology Observational RCT
Hygiene:
HWWS *** *** *** 48% *
Food *** * *
Sanitation
Water

16. Plausibility Microbiology Observational RCT
Hygiene:
HWWS *** *** *** 48% *
Food *** * *
Sanitation
Latrines *** * 36% *
Sewers ***
Water

17. Plausibility Microbiology Observational RCT
Hygiene:
HWWS *** *** *** 48% *
Food *** * *
Sanitation
Latrines *** * 36% *
Sewers ***
Water
Source *** *** ** 17%
HHWT *** *** *

18. Handwashing with
soap could save a
million lives a year...
…and prevent
cholera, ARIs, SARS,
pandemic flu,
neonatal mortality,
malnutrition, TE,
AIDS infections…

19. WASH externalities
•School attendance
•Labour saving
•Economic benefits
•Environmental protection
•Quality of life, beauty, dignity, social
exclusion...

20. Water MDG
JMP 2010

21. Sanitation MDG
JMP 2010

24. Country N HWWS HWWS HWWS HWWS HWWS HW with
after toilet after after before before water
(%) cleaning cleaning feeding handling only after
child (%) up child index food (%) toilet (%)
stools (%) child (%)
Ghana 500 3 2 - 1 - 39
India-Kerala 350 42 - 25 - - -
Madagascar 40 4 - - 12 - 10
Kyrgyzstan 65 18 0 - - - 49
Senegal 450 23 18 - - 18 -
Peru 500 14 - - 6 - -
China- Sichuan 78 13 - 16 6 - 87
China- Shaanxi 64 12 - - 16 - 14
Tanzania 30 13 13* 13* 4 - 33
Uganda 500 14 19 11 6 8 44
Vietnam 720 - 14 23 5 - 51
Kenya* 802 29 35 38 13 15 57%
Average 17% 13% 19% 5% 13% 45%

26. Time
Brain
Behaviour
Setting
Object
Evo-Eco Approach

27. design and formative research
testing
intervene setting brain
mass social planned
in behaviour health
community biological motivated
household physical habitual
Monitoring and evaluation

28. Origins
Human Motives
human Justice
primate Status
Affiliate
mammal Nurture Attract Play
Love Hoard
Fear Disgust
reptile Hunger Create Curiosity
Comfort Lust
body world brain

29. Formative research review
• Ghana, India (Kerala, AP),
Madagascar, Kyrgyzstan,
Senegal, Peru, China (Shaanxi,
Sechuan), Tanzania, Vietnam,
Uganda
Source: Curtis, Danquah Aunger, 2009

30. Motive 1: disgust
“When you are dirty you
shouldn‟t go out or meet
people-you risk
contaminating them or
upsetting them with
nauseous smells” (Senegal)
“Anything that comes out of the
human being is so bad.”
(Ghana)
“We wash our hands with soap
after we eat fish. Then we
will feel very uncomfortable,
our hands are stinking and
all” (Kerala)

31. Motive 2: comfort
“When I‟m clean, I‟m
comfortable” (Senegal)
„ “So that they feel fresh,
comfortable and smell like
soap.” (Peru)
“Soap makes clothes and
body smell good.”
(Kyrgyzstan)

32. Motive 3: nurture
“The children are my
future, so I should try
to look after them
well.” (Ghana)
“All I do is for my
children first, I work to
have money for my
children.” (Vietnam)

33. Motive 4: status
“Even if you are not polite and
well mannered, your
neighbours will respect you if
you are neat.” (Ghana)
“They will say that we are neat
and clean and when they tell
others, then we get respect of
others.” (Kerala)
“If you don‟t wash they look at
you like a pig at the school.”
(Peru)

34. Motive 5: affiliation
• “Washing hands to
fit in is very
common with us
here” (Uganda)
• “My relatives and
neighbours would
look at me.” (Peru)

35. Motive 6: attraction
“Dirt can even put away a
promising suitor”
(Ghana)
“When you have a
husband you have got
to show him a lot of
love. So I have to keep
my hands clean so that
I do not put any dirt on
him”(Uganda)

36. Motive 7: fear
• Child diarrhoea is not a threat, it is benign
and inevitable
• The belief link is tenuous, in the realm of
book learning, not directly experienced.
• Epidemics such as cholera may motivate
HWWS temporarily.
• Fear not a key motivator

37. Motives: conclusions
MOTIVATION GOOD CANDIDATE?
Disgust Yes
Fear No
Comfort Maybe
Nurture Yes
Affiliation Yes
Status No
Attraction No

38. Habit
• “That is what I do ever
since I was a child, I
remember when I was a
child, they kept telling me
to wash my hands with
water, but they never
mentioned soap.”
(Ghana)
• “Hand washing with soap
is not a habit round here.”
(Madagascar)

39. Behaviour modification
effective
understanding
communication
the drivers

40. Impact
•71% know TV ad
•69% can sing song
•Reported HWWS
-after defecation
+ 13%
-before eating
+ 41%

42. LADDU LINGAM Vs SUPERAMMA
Who makes better laddus?

45. • A cluster randomised trial
Trial results
of the results showed a
major and significant
improvement in
handwashing behaviour
(forthcoming)

46. • Theory-based
Lessons
• FR
• Commercial creative
agency
• Pretesting
• Emotion
• Scaleable...

51. Research • Food hygiene
• Dung!
• How to change behaviour?
• How to measure
behaviour?
• Role of Mass media
• BOP Products

52. Smart soap

54. Val’s MDGs • Every child protected by
HWWS
• Every child protected from
SHIT
• Every child gets safe food
• Every girl has dignified
MM
• Every school has HSW

55. Thank You

56. “Civilization can be measured
as the distance man has placed
between himself and his
excreta.” ~Brian Aldiss