A Life-Course Approach to Hygiene: Understanding Burden and Behavioural Changes
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A life-course approach to hygiene: understanding burden and behavioural changes Written by Table of Contents About this report Foreword Executive summary Introduction Chapter 1: Childhood and hygiene: a focus on diarrhoea Chapter 2: Adolescence and hygiene: a focus on menstrual hygiene Chapter 3: Adults and hygiene: a focus on slums Chapter 4: Older people and hygiene: a focus on respiratory hygiene Conclusion and policy takeaways References About this report A life-course approach to hygiene: understanding burden and This research covers the factors that need to be considered Extensive evidence was gathered from the literature and 11 behavioural changes is a report produced by The Economist to establish good hygiene practices and behaviour, with a expert interviews were conducted to help inform our research Intelligence Unit and sponsored by the Reckitt Global particular focus on four areas: diarrhoea, slums, menstrual and this report. Our thanks are due to the following for their Hygiene Institute. hygiene and respiratory hygiene. time and insights (listed alphabetically): Kelly Alexander Poornima Prabhakaran Julie Hennegan Senior learning and influencing advisor, Additional professor, head (environmental Research fellow, Maternal, Child and Water+, CARE, Atlanta, Georgia, US health) and deputy director, Centre for Adolescent Health Programme, Burnet Environmental Health, Public Health Institute, Melbourne, Australia; adjunct Foundation of India, India research associate, Johns Hopkins Bloomberg School of Public Health, US Jason Corburn Karin Leder Ian Ross Professor at the School of Public Health and Professor of clinical epidemiology and head Economist and PhD student (health Department of City and Regional Planning, of the infectious diseases epidemiology economics), London School of Hygiene and and director of the Institute of Urban unit at the School of Public Health and Tropical Medicine, UK and Regional Development, University of Preventive Medicine, Monash University, California, Berkeley, US Melbourne, Australia David Duncan Stephen Luby Joy Ruwodo Chief of WASH, UNICEF, Laos Professor of medicine (Infectious Diseases Director, public affairs for the Ending & Geographic Medicine) and director of Neglected Diseases (END) Fund Africa research at the Center for Innovation Region in Global Health, Stanford University, California, US Samayita Ghosh David Nabarro This report was led and edited by Elizabeth Sukkar of Senior research associate at the Centre Co-director of the Imperial College Institute for Environmental Health, Public Health of Global Health Innovation, London, The Economist Intelligence Unit and written by Ingrid Foundation of India, India UK; special envoy to the World Health Torjesen. It follows an initial phase of research—namely, Organisation (WHO) director-general a literature review, conducted by Bettina Redway and on covid-19; and strategic director of Alicia White with oversight by Rob Cook, looking at the 4SD (Skills, Systems and Synergies for burden of disease associated with hygiene practices. The Sustainable Development) findings and views expressed in this report are those of The Economist Intelligence Unit and do not necessarily reflect the views of the sponsor. February 2021 Hygiene has been brought sharply to the front of languished as a minority scientific and political interest our minds in 2020, as the world has grappled with for decades. Hygiene now deserves its rightful position Foreword the covid-19 pandemic. Never before have so many back at the centre, as the preventive component of the people been manoeuvred so quickly into new global fight against infectious disease. hygiene behaviours in the direct interest of public There are many gaps in our understanding: What are health. Although the efforts from governments, non- the key hygiene behaviours that are most effective in governmental organisations, the media and healthcare different settings? How can we best convince people to systems to create that behaviour change have been adopt and sustain them? Despite the ‘basic principle’ unprecedented, it has been far from universally above being intuitively true, what is the real cost- adopted, and its effectiveness continues to be debated. effectiveness of a given behaviour change in hygiene? The basic principle is rather simple: reduce the chance Wider society needs to recognise that practical, high- of transmission, and the burden of the disease on the quality scientific research will support the adoption population decreases. The cost and effort of treating of globally sustainable hygienic practices and achieve people declines, and fewer people perish. enduring behaviour change. How can it be done? By For most infectious diseases, particularly in high- expanding the body of research around and advance income countries, therapeutic options have burgeoned the understanding of the links between hygiene and through the 20th century and into the 21st, and florid health; enhancing the understanding of hygiene science cases rarely present to front-line healthcare. This has to encourage new hygiene standards; promoting allowed a degree of complacency to develop. However, behaviour change to improve global hygiene and we have gradually started to recognise that antibiotics health; and informing the global public health agenda. have a limited lifecycle before resistance renders them If these things can be done, policymakers can more Peter Piot useless; and effective treatments for viral infections successfully drive locally relevant and effective hygiene FCMG FRCP FMedSci have often proved elusive. We have seen heroic efforts policies that improve community and individual health Director, London School of Hygiene in vaccine development – necessarily after the fact and development outcomes. & Tropical Medicine – to battle epidemics and pandemics of emerging This Report is the first commissioned by RGHI. It Chair, RGHI Expert Panel infections, including the present one. And so far, each highlights the burden created by deficits in hygienic time, we have enjoyed the feeling that the panic is over. practice and examines the behavioural and societal But just as good diet and lifestyle function to reduce challenges that need to be addressed in key settings. the chance of developing diabetes and heart disease, We are grateful to Rob Cook, Elizabeth Sukkar and their Simon Sinclair we need to recognise the truth that ‘prevention is team at the Economist Intelligence Unit, and the many better than cure’ in infectious disease too. Hygiene researchers and experts who brought their expertise to PhD MB BChir Executive director, RGHI has historically contributed enormously in this regard, this project. from the Romans’ great aqueducts to Semmelweis’ handwashing efforts against puerperal fever. But it has Executive Summary Hygiene refers to the practices that help to maintain health Life stage Influencers and prevent the spread of diseases. While good hygiene is primarily about behaviours, the ability to practise them well Parents/caregivers Childhood and hygiene: is supported by having the appropriate infrastructure in Nursery and school a focus on diarrhoea place, such as access to clean water and soap. Wider family and friends Maternal and healthcare services Poor water, sanitation and hygiene (WASH) increases Childhood Public health initiatives death rates and ill health, creates greater demand for Society and media Every year diarrhoeal diseases kill around 0.5m healthcare interventions, widens social inequalities, and children under five,1,2 with the majority of deaths has repercussions for quality of life and the wider economy. in South Asia and sub-Saharan Africa. 3,4 The There are two main transmission routes for infection— majority of diarrhoeal deaths in low- and middle- the faecal-oral and respiratory pathways—and hygiene Parents/caregivers income countries (LMICs) across all age groups measures work by disrupting them. School and university can be attributed to WASH.5 Handwashing with Wider family and friends soap can reduce transmission of diarrhoeal Attaining good hygiene is complex, and it is becoming Healthcare services and public health initiatives Adolescence diseases and, to a lesser extent, respiratory increasingly clear that a more holistic approach is needed Society and media infections.6 It is estimated that handwashing with that engages and empowers local populations, and is locally soap after faecal contact only occurs in about sensitive and sustainable. 26% of events globally7,8 and the frequency of The life-course approach, which has its origins in preventing handwashing was lowest in regions with poor access to handwashing facilities. In 2017 the or reducing the impact of non-communicable diseases Work environment UN estimated that 3bn people lacked basic through encouraging good behaviours while recognising the Wider family and friends 9 contribution of other factors, including environmental ones, Healthcare services and public health initiatives handwashing facilities at home. Furthermore almost half (47%) of schools worldwide lack could provide a useful framework for communicable disease Adulthood Society and media and hygiene. Looking at hygiene through a life-course handwashing facilities with available soap and 10 lens could form part of a smarter approach that embeds water, and one in four health care facilities lack 11 good hygiene behaviour from childhood (to gain the most basic water services. cumulative benefit), and then reinforces it throughout a Experience from