Hi Professor Gehring,

Thank you for your question. There are several social barriers to hand washing with soap that were identified. The first barrier was that while soap was readily available except for those more socio-economically disadvantaged, availability of soap did not necessarily equate with use of soap for hand washing. Soap was viewed as a luxury item by some households that reported soap was always available. Instead of utilizing soap consistently to wash body and hands, soap was instead utilized in the following ways: (1) as a lotion after bathing and (2) for washing clothes. Soap was also predominantly used for hand washing after eating fatty foods which occurred frequently on holidays or other special occasions.

The second barrier was the perception that washing with only water and no soap was sufficient to remove contaminants from hands. Community members practice visual inspection of hands for dirt as a way to determine when to hand wash and the completeness of their hand washing. Such a practice is a misleading diagnostic because an important factor for hand washing is the reduction of microbial contamination on hands which cannot be visually ascertained.

Thank you, Matthew.
Catherine

Hi Professor Lefticariu,

The short answer to your question is that families were not directly told by us of preventative measures. The results were disseminated in a town meeting and a report to pertinent officials as this was the most politically expedient way to discuss this somewhat surprisingly sensitive topic.

The long answer is that you are definitely correct that soap is expensive for many African families. In addition, behavioral change is quite difficult. There was a review study conducted by Chase & Do (2012) for large-scale public health campaigns focused on hand washing found that sustained behavioral change even under ideal conditions was very difficult.

One of the central conclusions of this study was that water continued to become contaminated from source to household. While the preventative measure of digging latrines away from water sources could prevent contamination of water sources, it does not ensure that water at consumption will be safe since the sources of contamination (i.e., hand contamination) have not been sufficiently addressed.

A follow-up preventative measure was to investigate centralized gravity driven chlorine dosers for use in rural and peri-urban areas in this region since behavioral change at the household may not be required. Chlorine is effective for a vast majority of pathogens excluding protective cysts formed in species such as cryptosporidium. The results of this follow-up study suggest that chlorination will be effective only up to six hours, and would require some change in household storage habits to be effective. Thank you!

Dear Professor Rios,

Thank you for your interesting questions.

I have thought about the kind of education campaign needed especially given that hand washing with soap is not a widespread phenomenon around the world. Campaigns in the context of Ethiopia typically come about from health extension workers and with the best of intentions. Some of the campaigns are very successful. For example, the Ethiopian government and several NGOs such as WaterAID and World Vision have conducted extensive campaigns against open defecation, and there is documented evidence that there has been widespread success in convincing farmers to construct dry pit latrines in the Amhara highlands region of Ethiopia. Farmers were convinced through a very simple demonstration by showing how feces can be transmitted in the environment. However, even with these substantial infrastructure improvements, there are further implications to research and understand such as water source contamination from the dry pit latrine and the effectiveness of dry pit latrines in preventing disease transmission.

For a hand washing campaign, I think that it would be better for it to be led by the community and assisted by the government as opposed to the typical model where the government or NGOs more or less dictate the new behavior. Particularly, women should be the focus of the campaign, and there should be a simple and truthful demonstration that convinces the community to change and take action. I think the difficulty with hand washing is that there is not necessarily a simple and effective demonstration that may be convincing. I have seen hospitals in the US utilize dye and black lights to test and demonstrate decontamination from hand washing. There is no visual feedback that would convince one that using soap gets rid of contamination more readily than simply using water. I could envision coating hands with some more non-polar such as an oil substance, but the people already practice hand washing with soap after eating heavily fatty or oil foods. Soap is also very expensive for many people so there would need to be more of an incentive based system or a centralized distribution that is somewhat subsidized in my opinion.

Concerning chlorine use, while this was not part of the study, we did have a follow-up study where we investigated chlorination in rural areas. One aspect of this study included a participatory focus group where we dosed chlorine at varying concentrations up to 8 mg/L to test taste and smell threshold of participants. The results were encouraging in that the majority of respondents did not note a negative response until a dose between 4 – 8 mg/L. In addition, these people have had experience with chlorine. The government distributes single doses (25-50 grams) every few months. Such a method is not effective as it initially severely over doses the water and then does not provide residual protection after the dose becomes flushed out.

Dear Professor Yeakley,

Thank you for your question. There have been several steps to transfer the findings of this study to the town of Agew Gimjabet and the surrounding rural areas. First, a follow-up study was conducted that was a pilot study that investigated utilizing a centralized, gravity driven chlorine doser for rural areas. The results are not published yet and we are still working to scale-up the technology, and lower costs further.

Secondly, the results were disseminated to the community in two forms: (1) there was a community meeting where community members were invited and able to ask questions about the study results and talk about what steps they personally wanted to take, and (2) there was a meeting with administrators in the community where the results were presented.

Finally, collaborators and I have met with the Finnish NGO FINNIDA and presented our findings at a WASH development conference in Addis Ababa. FINNIDA is primarily concerned with construction and then management and sustainability of spring or hand pump water sources. We are also in talks with FINNIDA to expand services to include our pilot scale gravity driven chlorinator. However, this is still in the development phase.

Also, I did not specify this in the presentation, but the data collection phase for this project is only one year old.

Hi Joseph-Thank you for you interest! One of the goals of the project is to understand ways that individuals can use information to eventually change their behavior.

Hi Kyana-Great question! Hand washing availability was another factor investigated, but not presented or discussed here. One of the survey questions was to report soap availability. For the majority of users except for those more economically disadvantaged, soap was available. While people washed their hands before and after meals, soap was often not used. We investigated this further and found that soap in this town was used primarily as lotion after showering and particularly with hand washing after eating fatty foods which mostly occurred during holidays.

I agree that there are ways to make sanitation and hygiene affordable for the vast majority of people. I think it’s important to understand the appropriate and user friendly technology and the institutions that are required to make this possible. I am not sure if we can expect government and NGO subsidization, therefore, I think there is more research and development required to bring down costs that are truly affordable.

Hi Tony,

The only relief aid for WASH was through the Finnish NGO FINNIDA and the British NGO WaterAID. Generally these concerned construction of water points and distribution of chlorination tablets. It would be very interesting to explore effective relief methods for sanitation and hygiene here though since soap is not affordable for some of the people here.