Washing Away Dirty Habits

ETHICS + POLICY

Credit: Amy Pickering

by SHELLY AMIEVA

Washing Away Dirty Habits

Hygiene education as a tool for preventing water-related diseases

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By the time you finish reading this sentence one more child will have died from a water-related disease. According to an official message by former U.N. Secretary Kofi Annan, “water-related diseases kill a child every eight seconds.” Consistent access to clean water is a rare commodity for every one in six persons, and 2.4 billion individuals “lack access to adequate sanitation.”

Not only do such statistics make us question the success of past and current policies addressing water access and sanitation but they also raise the question of what strategies are most effective for preventing water-related illnesses. From an epidemiological perspective, is access to potable water more effective for preventing disease than sanitation?

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Credit: Amy Pickering

ETHICS + POLICY

Left, Jenna Davis meets with her research project participants.

“Sanitation is at least as effective in preventing disease as improved water supply. Often, however, it involves major behavioral changes and significant household cost.” – World Health Organization For instance, the Romans demonstrated they were more concerned about water infrastructure than sanitary practices and hygieneo by investing greatly in aqueducts but dumping sewage into nearby rivers that were also used for drinking water. However, according to a report released by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), “sanitation is at least as effective in preventing disease as improved water supply. Often, however, it involves major behavioral changes and significant household costs.” Research conducted by Dr. Jenna Davis, Assistant Professor of Civil and Environmental Engineering and Center Fellow at the Woods Institute for the Environment, explores the impact of increasing hygiene education on health outcomes. In the summer of 2008, Davis conducted a sanitation research project in Dar es Salaam, Tanzania to determine whether providing personalized information is more effective for modifying hygienic behavior than to providing generic information. Davis’s sanitation project in Tanzania is unique and innovative because it focuses on changing human behavior to improve sanitation as opposed to solely relying on technology or infrastructure. Her

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approach is important because modernizing infrastructure in developing countries to improve sanitation and increase access to clean water is a costly and slow process, usually further impeded by political corruption and bureaucracy. Her project can produce useful data for creating and developing models to help analyze and improve sanitation in regions of developing countries that have conditions similar to those in Tanzania.

Gauging the Impact of Education on Hygiene Habits

Davis’s study was conducted in the coastal city of Dar es Salaam. This city is the capital of Tanzania, a country that ranks 152nd out of 179 countries in the U.N.’s Human Development Index. The U.N.’s Human Development Index 2008 Statistical Update reports that the average life expectancy in Tanzania is 51.6 years and 45% of people do not have access to an improved water source. Therefore, Dar es Salaam was a prime urban region to conduct a study on sanitation, hygiene and access to clean water. As reported in “646 Very Personal Questions” by Robert Strauss, Davis’s research team created a questionnaire that asked 646 questions on “habits regarding water,

To investigate whether personalized information is more effective than generic information for improving hygiene, the Tanzanian households were separated into four different groups. These groups differed in the amount of feedback they received, but by the end of the study all four groups had been given the same information. Researchers then compared the incidence of diarrhea among these four cohorts to determine whether or not personalized information is more effective for prompting changes in hygienic habits. They were also “look[ing] at proximal indicators such as attitudes and behaviors, whose change we would expect to eventually result in health impacts,” says Davis. Although Davis and her research team are still in the process of analyzing the data, they have already made one very interesting find. According to Davis “[mothers in the control group, meaning those who] received a set of information about links between water, sanitation, hygiene and health as well as strategies to reduce their risk of illness, are showing the same gains in terms of their knowledge, attitudes, perceptions, and reported behavior changes as the cohorts that received the individualized test results. It seems that the information itself was exceedingly powerful.”

Implications

One of the Millennium Development Goals is to provide 1.5 billion people access to an improved water supply. One would assume that if this goal were to be achieved, a significant decrease in mortality and morbidity concerning water related illnesses should follow. However, this might not necessarily be the case. Davis explains that the problem may lie in the definition of “access to improved water source.” The U.N. defines “improved water sources” as “levels of services that are more likely to provide safe water than unimproved technologies. Improved water sources include household connections,

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sanitation and hygiene.” Trained Tanzanians personally administered the survey questions to a total of 330 households. The research team took samples from every member of the 330 households, on four separate occasions, to test for the presence of Enterococcus and E. coli.

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ETHICS + POLICY

Above, a girl with two buckets of water. Left, two children pose with empty cans.

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ETHICS + POLICY

20 liters per capita per day is an inadequate amount of water to conduct proper hygiene and consequently prevent disease. public standpipes, boreholes, protected dug wells...” Access to that source of water is defined as “availability of at least twenty liters per person per day from a source within one kilometer of the user’s dwelling.”

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As Davis points out, 20 liters per capita per day is an inadequate amount of water to conduct proper hygiene and consequently prevent disease. According to the American Water Works Association, the average American consumes a total 159.7 liters of water through the use of showers, faucets, toilets, and baths. Therefore, Davis says that the challenge for her and other researchers is to “actually understand the contribution that [this level of service] makes or doesn’t make to health outcomes.” Her research team is trying to “draw more attention to the extra infrastructural interventions that might be considered alongside improvements in water and sanitation hardware that might result in maximum health gains.”

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What regions of the world could benefit from this study? Davis points out that to answer this question one has to consider the context in which the research was carried out. For instance, this study was conducted in an urban area where “people have the means to act on their motivations” such as “markets, social networks, and organizations such as NGOs.” Additionally, the project targeted “communities where households are relying on shared point water sources and on site sanitation.” Therefore, the regions that might benefit from this research include Sub-Saharan Africa, South Asia, and Southeast Asia. This sanitation project in Dar es Salaam is unique because it takes a holistic approach that encompasses issues concerning water access, sanitation, and hygiene to solve deadly public health challenges. This approach is also essential because, according to the article “Environmental Interventions in

Developing Countries: Interactions and Their Implications” published in the American Journal of Epidemiology: “In all cases, the positive impact of improved water quality is greatest for families living under good sanitary conditions.”

Harnessing the Power of Knowledge

Because this project was conducted in collaboration with the Dar es Salaam Water Supply and Sanitation Authority, the Muhimbili University of Health and Allied Sciences and two NGOs, the findings of this study can be channeled through more than just one mainstream source and consequently reach a greater number of people more readily. Davis happily reports that even though the data from this project has not yet been published, its findings are already being put into use. For instance, in the past the Dar es Salaam Community Water Supply and Sanitation Program had focused only in improving water supply infrastructure but it did not observe a decrease in water-related illnesses. Now it is planning to incorporate elements of Davis’s findings to create a complementary hygiene and sanitation educational program. In theory, the ancient Romans had it right when they recognized that “in aqua sanitas” (in water there is health) but new studies, such as the one in Tanzania are demonstrating that this saying should be extended to say “in water and education there is health.”

To Learn More

For more information, check out the Dar Es Salaam Community Water Supply and Sanitation Program reports at the World Bank website, http://www-wds.worldbank.org/.