Promoting the simple act of hand washing can save lives in many developing countries, according to a new systematic review of studies.
The review, led by Regina Ejemot of the University of Caliber, in Nigeria, shows that teaching people about hand washing can reduce the incidence of diarrhea by up to 30 percent and might have as great an affect as providing access to clean water.
“Our review specifically assessed the effects of interventions to promote hand washing and not the effectiveness of improving sanitation,” Ejemot said. “However, common sense would suggest that there has to be water for hand washing to happen, regardless of community awareness of benefits or willingness to wash hands.”
The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.
The researchers summed up the results of 14 studies of hygiene promotion practices in institutions, community organizations and homes. Eight studies monitored 7,711 participants in institutions such as day care centers in high-income countries. Five community-based studies with 8,055 participants took place in low and middle-income countries and one study looked at the practices of 148 members of a high-risk group of AIDS patients.
The review found that interventions promoting hand washing resulted in a 29 percent reduction in diarrhea episodes in high-income countries and a 31 percent reduction in such episodes in communities in low- and middle-income countries.
“Poor access to safe water is directly linked with increased morbidity and mortality from waterborne and fecal-oral diseases — especially diarrhea,” Ejemot said.
Water availability alone does not ensure hand washing. Hygiene promotion requires trained personnel to lead programs, the involvement of community organizations as well as providing soap and water.
Hygiene promotion methods studied included small group discussions and larger meetings, multimedia communications campaigns with posters, radio and TV campaigns, leaflets, comic books, songs, slide shows, use of T-shirts and badges, stories, drama and games.
“It is difficult for people in developed countries to realize that diarrhea is still a major cause of deaths in developing countries, killing more children than AIDS and malaria combined,” said Dr. Olivier Fontaine, a specialist with Child and Adolescent Health and Development with the World Health Organization (WHO).
WHO estimates that diarrhea is responsible for over 2.2 million deaths annually, especially in children under the age of five. It is an important cause of malnutrition in resource-poor countries and, if persistent, can contribute to decreased resistance to infection and hamper children’s growth and development.
Infection by the germs that cause diarrhea occur by consuming contaminated food and drink, by person-to-person contact or by direct contact with feces. In many resource-poor countries, people do not have the toilets and the infrastructure to support them.
In some cases, the whole family might simply dip their hands in the same bowl of water before eating, making it likelier that they will spread germs.
One study found that hand contact with ready-to-eat food consumed without further washing or cooking could be even more effective at transmitting germs than food that is prepared and cooked at home.
In some settings, cultural attitudes can be part of the problem.
“Hand washing is influenced by community perception of what is hygienic or not,” Ejemot said. “For instance, stools passed by infants are considered harmless, probably as harmless as the baby. This perception makes hand washing following disposal of the baby’s stool not a necessary hygiene practice. Such a community would need cultural and behavioral change to accept hand washing.”
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