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Cited by 228Child Nutrition and Water AccessFood Safety and HygieneInfection Control in Healthcare

Hygiene: new hopes, new horizons

Open access
Curtis, Val, Schmidt, Wolf, Luby, Stephen, Florez, Rocio, Touré, Ousmane, Biran, Adam·2011·The Lancet Infectious Diseases
DOI 10.1016/s1473-3099(10)70224-3PMC PMC7106354
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Abstract

Review on the public health importance of hygiene and behaviour change in low- and middle-income settings.

Integrity signals

Registry

Crossref · 10.1016/s1473-3099(10)70224-3

Cites

78 of 78 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

26 of 104 cited sources checked · 13 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Trials of promoting exclusive breastfeeding on food-borne infections have equivocal results.

    “Several trials have assessed the effect of promoting exclusive breastfeeding on food-borne infections, with equivocal results.28, 29”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [28] Bolam, 1998, The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled trial, BMJ source

      The Protocol says this randomised trial promoted exclusive breastfeeding, and the Abstract reports no significant difference in infant-feeding practices. But the Outcome measures section lists mothers’ knowledge of diarrhoea management, not infants’ food-borne infections; the trial therefore does not establish an equivocal effect on those infections. Page numbers are unavailable in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [29] Jakobsen, 2008, Promotion of exclusive breastfeeding is not likely to be cost effective in West Africa. A randomized intervention study from Guinea-Bissau, Acta Paediatr source
  • Premisecitation

    Handwashing can reduce respiratory infection by 16% according to one review.

    “Handwashing can also reduce other infections; one review suggested it could reduce respiratory infection by 16%,13”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [13] Rabie, 2006, Handwashing and risk of respiratory infections: a quantitative systematic review, Trop Med Int Health source
  • Premisecitation

    In a motorway service station in south England, 65% of women and 31% of men washed their hands with soap after using toilet facilities.

    “In a motorway service station in the south of England, just 65% of women and 31% of men washed their hands with soap after using the toilet facilities,62”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [62] Judah, 2009, Experimental pretesting of hand-washing interventions in a natural setting, Am J Public Health source

      The Results report blank-control soap-use ratios of 0.651 for women and 0.317 for men, close to the cited 65% and 31%. The Methods locate the service station in England but do not specify the south; they also describe the figures as ratios of soap-dispenser uses to restroom entries, rather than directly observed proportions of individuals washing their hands. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Premisecitation

    A review of 11 studies in Africa, Asia, and Latin America concluded that common patterns exist despite local differences.

    “A review of 11 studies done in Africa, Asia, and Latin America concluded that, although there are local differences, common patterns exist.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source

      The Discussion (‘Similarities and differences’) says that handwashing practices and their determinants differed between countries, but that the findings were strikingly similar. The Introduction and Methods specify 13 studies across 11 countries—not 11 studies—including countries in Africa, Asia and Latin America. (LLM, conf=0.93)

      Experimental — accuracy not yet measured
  • Premisecitation

    Other motivations for handwashing include comfort and nurturance.

    “Other motivations included comfort and nurturance (the desire to care for one's children).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source
  • May combine two claims. 45
  • Classified as probably not a substantial claim. 28

  • May combine two claims.

    Premisecitation

    Handwashing reduces neonatal mortality, trachoma, and parasitic worm infections.

    “Handwashing also reduces neonatal mortality,15 trachoma,16 and parasitic worm infections.17”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [15] Rhee, 2008, Maternal and birth attendant hand washing and neonatal mortality in southern Nepal, Arch Pediatr Adolesc Med source

      The Results and Discussion report significantly lower neonatal mortality associated with maternal and birth-attendant handwashing in southern Nepal. The source does not establish that handwashing caused the reduction; the Discussion acknowledges possible residual confounding. Trachoma and parasitic worm infections have separate citations in the citing sentence and are not attributed to this source. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [16] Emerson, 2000, A review of the evidence for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma control, Trop Med Int Health source
    • cites [17] Fung, 2009, Ascariasis and handwashing, Trans RSoc Trop Med Hyg source

  • May combine two claims.

    Premisecitation

    Handwashing with soap mitigated the SARS epidemic and is recommended to counter possible influenza pandemics.

    “Handwashing with soap mitigated the severe acute respiratory syndrome epidemic22 and is one of the key practices recommended to counter possible influenza pandemics.23”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [22] Fung, 2006, Effectiveness of handwashing in preventing SARS: a review, Trop Med Int Health source

      The Results report that handwashing was associated with reduced SARS infection in nine of ten studies' univariate analyses. But the Discussion says the evidence that handwashing was effective is suggestive, not conclusive; it does not establish that washing with soap mitigated the epidemic. The influenza-pandemic recommendation carries a separate citation (23), so it is not attributed to this paper. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [23] Jefferson, 2008, Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review, BMJ source

      The Results report that washing hands more than 10 times daily was associated with lower odds of SARS in six case-control studies. Those SARS findings do not specify soap, and the paper describes the evidence as suggesting effectiveness rather than establishing that handwashing mitigated the epidemic. The influenza-pandemic recommendation carries a separate citation in the citing sentence. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Lack of water and a perception that soap is too expensive could constrain handwashing, though this might be post-rationalisation because soap was present in 97% of households in a review but used mainly for clothes, body, and dish washing.

    “Lack of water and a perception that soap is too expensive for handwashing could also constrain handwashing (though this might be post-rationalisation because one review suggested that soap was present in 97% of all households in a review, but it was used mainly for clothes, body, and dish washing).56”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source

      The Results (‘The environment’; page unavailable) describe water access and soap cost as possible constraints, and report soap in at least 95% of households in studies that recorded it—not 97% of all households. The paper mentions laundry soap and questions the reliability of self-reported reasons for handwashing, but the cited passages do not establish that soap was used mainly for clothes, body and dish washing. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Mothers did not find the threat of diarrhoeal disease relevant and found the connection between handwashing and child diarrhoea tenuous.

    “Mothers did not find the threat of diarrhoeal disease particularly relevant and found the connection between handwashing and possible diarrhoea in children tenuous.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source

  • May combine two claims.

    Premisecitation

    Mothers planned to teach children good manners and to economise by not wasting soap.

    “Mothers did, however, plan to teach their children good manners, and they also planned to economise by ensuring that soap was not wasted.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source

  • May combine two claims.

    Premisecitation

    Key motivations for handwashing are disgust of contamination on hands and perceived social norms.

    “Key motivations for handwashing were disgust of contamination on hands and to do what everyone else was perceived to be doing (social norms).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source

  • May combine two claims.

    Findingcitation

    Handwashing with soap by child carers at key moments is rare, varying from 3% in Ghana to 42% in Kerala, India.

    “Handwashing with soap by child carers at key moments, such as after using the toilet, was rare, varying from 3% in Ghana to 42% in Kerala, India.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source
    • cites [57] Luby, 2009, Household characteristics associated with handwashing with soap in rural Bangladesh, Am J Trop Med Hyg source

      The Introduction (p. 1) says handwashing with soap after fecal contact is typically below 30% in settings where diarrhea is a major cause of child mortality, and the Results (p. 3) report 18% after observed fecal contacts in rural Bangladesh. Our copy does not give the claimed 3% figure for Ghana or 42% figure for Kerala, India, so it supports the general rarity but not the stated range. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Hygiene habits are learnt at an early age, but soap use is rarely taught by parents or schools.

    “Hygiene habits were learnt at an early age, but soap use was rarely taught by parents or schools.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [56] Curtis, 2009, Planned, motivated and habitual hygiene behaviour: an eleven country review, Health Educ Res source

  • May combine two claims.

    Premisecitation

    A water-treatment and handwashing intervention in Kenya and an intensive handwashing education programme in Chinese primary schools both reduced absenteeism.

    “data from a water-treatment and handwashing intervention in Kenya and an intensive handwashing educational programme in Chinese primary schools showed a reduction in absenteeism.77, 78”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [77] Bowen, 2007, A cluster-randomized controlled trial evaluating the effect of a handwashing promotion program in Chinese primary schools, Am J Trop Med Hyg source
    • cites [78] O'Reilly, 2008, The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, western Kenya, Epidemiol Infect source

  • May combine two claims.

    Findingnone given

    Very few RCTs of hygiene promotion programmes have been undertaken in developing countries, and those done have methodological flaws.

    “However, very few RCTs of hygiene promotion programmes have been undertaken in developing countries, and those that have been done have several methodological flaws.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    No known studies have quantified the risks associated with using cow dung for fuel or in house maintenance.

    “However, no studies that we know of have quantified the risks associated with the use of cow dung for fuel or in house maintenance.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    The biological plausibility of most hygiene interventions is high.

    “The biological plausibility of most hygiene interventions is high (table 1);”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    After Programme Saniya ran for 3 years, three-quarters of targeted mothers had been involved and half could cite the two main messages correctly.

    “After the programme had run for 3 years, three-quarters of the mothers targeted had been involved with programme activities and half could cite the two main messages of the programme correctly.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Safe food handling and preparation, avoiding animal faeces, and safe water storage and use are important, especially for children.

    “Safe food handling and preparation is also important, especially for children, as is the avoidance of animal faeces and the safe storage and use of water.3”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Curtis, 2000, Domestic hygiene and diarrhoea, pinpointing the problem, Trop Med Int Health source

  • May combine two claims.

    Premisecitation

    Face or whole-body washing might help control skin infections and trachoma.

    “Face or whole-body washing are less well researched but might help to control skin infections and trachoma.18”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Ngondi, 2009, Evaluation of three years of the SAFE strategy (Surgery, Antibiotics, Facial cleanliness and Environmental improvement) for trachoma control in five districts of Ethiopia hyperendemic for trachoma, Trans R Soc Trop Med Hyg source

  • Classified as probably not a substantial claim.

    Premisereasoning

    Adequate handwashing after contact with faeces is crucial.

    “Adequate handwashing after contact with faeces is also crucial (after one's own defecation, after handling the faeces of children, or after contact with a faeces-contaminated environment).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Observational correlations between hygiene practices and disease incidence are more available but can be misleading.

    “These data are more readily available, but can be misleading.6”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] Blum, 1983, Measuring the impact of water supply and sanitation investments on diarrhoeal diseases: problems of methodology, IntJ Epidemiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Adequate hygiene can prevent respiratory infections, trachoma, and skin infections.

    “Other diseases that can be prevented by adequate hygiene include respiratory infections, trachoma, and skin infections.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The main missing element is full active engagement of the health sector in improving global hygiene.

    “The most important ingredient still missing is the full and active engagement of the health sector in improving global hygiene.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Too few health professionals are engaged in programmes to promote hygiene.

  • May combine two claims.

    Premisecitation

    Evidence from all four sources consistently shows handwashing interventions reduce diarrhoea by about 30%, and by 43-47% when soap is used.

    “Evidence from all four types of source is consistent, with RCTs of handwashing interventions showing reductions in diarrhoea of around 30%, and of 43–47% if soap is used.11, 12”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [11] Curtis, 2003, Effect of washing hands with soap on diarrhoea risk in the community: a systematic review, Lancet Infect Dis source
    • cites [12] Ejemot, 2008, Hand washing for preventing diarrhoea, Cochrane Database Syst Rev source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Improved water supplies and sanitation facilities make hygiene easier and protect children and adults from infection.

    “Improved water supplies and sanitation facilities make it easier to practise hygiene, keeping children and adults safe from infection.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    Improvements in hygiene, sanitation, and water can prevent several important infections and provide other benefits.

    “Improvements in hygiene, sanitation, and water can prevent several important infections, in addition to providing other benefits.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Contaminated weaning food has been suggested as a major contributor to diarrhoea in low-income settings, though observational studies are inconclusive.

    “Contaminated weaning food, in particular, has been suggested as a major contributor to diarrhoea in low-income settings,26 although observational studies gave inconclusive results.24”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [26] Motarjemi, 1993, Contaminated weaning food: a major risk factor for diarrhoea and associated malnutrition, Bull World Health Organ
    • cites [24] Lanata, 2003, Studies of food hygiene and diarrhoeal disease, Int J Environ Health Res source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Preventing diarrhoeal diseases is the most important among avoidable infections.

    “Among these avoidable infections prevention of diarrhoeal diseases is most important.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Investment in hygiene is low in both the health sector and the water and sanitation sector.

    “Although promotion of safe hygiene is the single most cost-effective means of preventing infectious disease, investment in hygiene is low both in the health and in the water and sanitation sectors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Masking participants in hygiene trials is difficult; grateful mothers may underreport disease in their children, inflating effect sizes.

    “For example, the masking of participants to the intervention is difficult, and as a result, mothers who are grateful for an intervention may be less likely to report disease in their children, leading to inflated effect sizes.9”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Wood, 2008, Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study, BMJ source

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationnone given

    The evidence for giving hygiene a much higher priority is strong, and the necessary actions are largely known.

    “The evidence for giving hygiene a much higher priority is strong, and, to a large extent, we already know what needs to be done.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Risk mapping approaches depend on good estimates of environmental contamination, which are largely unavailable for developing countries.

    “However, these approaches depend on access to good estimates of environmental contamination, which are largely unavailable for developing countries.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Full active involvement of the health sector in delivering safe hygiene to all homes, schools, and institutions will bring major public health gains.

    “Full and active involvement of the health sector in getting safe hygiene to all homes, schools, and institutions will bring major gains to public health.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Most sanitation and water supply programme implementers seek to improve hygiene alongside hardware but rarely have the resources and professional support to do this effectively.
    • Rests on an assumption: Too few health professionals are engaged in programmes to promote hygiene.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Other ways to prevent faecal-oral transmission include keeping water, foods, and surfaces free of faecal contamination and preventing carriage by flies.

    “Other ways of preventing the faecal–oral transmission of infections include keeping water, foods, and surfaces free of faecal contamination and preventing carriage by flies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Other obstacles include absence of hard surfaces, unavailability of cleaning materials, and limited access to hygiene aids.

    “Other obstacles include the absence of hard surfaces that can easily be kept clean, unavailability of cleaning materials such as soap and surface cleansers, and limited access to hygiene aids, such as potties or nappies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Household surfaces seem to play a major part in disease transmission, though most evidence is from developed countries.

    “Household surfaces seem to play a major part in disease transmission, although most evidence is from developed countries,39, 40, 41”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [39] Barker, 2000, Survival of Salmonella in bathrooms and toilets following salmonellosis, J Appl Microbiol source
    • cites [40] Cozad, 2003, Disinfection and the prevention of infectious disease, Am J Infect Control source
    • cites [41] Cogan, 2002, Achieving hygiene in the domestic kitchen: the effectiveness of commonly used cleaning procedures, J Appl Microbiol source

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Information suggesting handwashing with soap is a desirable social norm could be helpful where it is not one.

    “as could information suggesting that handwashing with soap is a desirable social norm where it is not one.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A national handwash programme in Ghana using disgust and nurture increased self-reported handwashing before eating by 41% and after defecation by 13%.

    “A national handwash programme in Ghana that used disgust and nurture to motivate handwashing increased self-reported handwashing before eating by 41% and after defecation by 13%.51”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [51] Scott, 2007, Marketing hygiene behaviours: the impact of different communications channels on reported handwashing behaviour of women in Ghana, Health Educ Res

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationcitation

    The weight of evidence suggests hygiene promotion reduces disease, can be delivered directly and by mass media at relatively low cost per person, and has few adverse effects.

    “The weight of evidence suggests that hygiene promotion is effective in reducing disease, can be promoted both directly and by mass media programmes with relatively low expenditure per person targeted,1, 51 and has few adverse effects.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [1] Jamieson, 2006

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [51] Scott, 2007, Marketing hygiene behaviours: the impact of different communications channels on reported handwashing behaviour of women in Ghana, Health Educ Res

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Programme Saniya increased observed handwashing with soap by mothers from 1% to 17% after using the toilet and from 13% to 31% after cleaning a child.

    “The project increased observed handwashing with soap by mothers from 1% to 17% after using the toilet and from 13% to 31% after cleaning up a child (panel 1 ).72”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [72] Curtis, 2001, Evidence for behaviour change following a hygiene promotion programme in West Africa, Bull World Health Organ

  • Classified as probably not a substantial claim.

    Interpretationcitation

    Changing four distinct hygiene practices over a short time is unrealistic.

    “perhaps suggesting that changing four distinct hygiene practices over a short time is unrealistic.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Hygiene promotion can already be recommended for large-scale implementation.

    “Although additional intervention trials using improved outcome measures are urgently needed to confirm previous findings, hygiene promotion can already be recommended for large-scale implementation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationnone given

    How insight into determinants can be used in behaviour change programmes is not always obvious.

    “Although an understanding of the determinants of handwashing behaviour is helpful, how such insight can be used in behaviour change programmes is not always obvious.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In some settings fly control might reduce diarrhoea risk by around 25% and lessen trachoma risk.

    “In some settings fly control might reduce diarrhoea risk by around 25%,46, 47, 48 and lessen the risk of trachoma.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [46] Chavasse, 1999, Impact of fly control on childhood diarrhoea in Pakistan: community-randomised trial, Lancet source
    • cites [47] Emerson, 1999, Trachoma and fly control, J Comm Eye Health
    • cites [48] Emerson, 1999, Effect of fly control on trachoma and diarrhoea, Lancet source

  • Classified as probably not a substantial claim.

    Premisecitation

    Whether an intervention can be recommended depends on evidence of disease reduction, scalability, acceptability, and risk of adverse effects.

    “Whether an intervention can be recommended for implementation depends not only on the evidence of disease reduction, but also on its scalability, acceptability, and the risk of adverse effects.50”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [50] Ross, 2006, The weight of evidence: a method for assessing the strength of evidence on the effectiveness of HIV prevention interventions among young people, World Health Organ Tech Rep Ser

  • May combine two claims.

    Interpretationnone given

    Changing behaviour is difficult, but knowledge about hygiene behaviour has increased and promising large-scale approaches are emerging.

    “Though changing behaviour is difficult, we know a lot more about hygiene behaviour than we did 10 years ago and promising approaches to changing hygiene on a large scale are emerging.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Changing hygiene behaviour requires addressing one or several of these factors, which requires better understanding of them.

    “For behaviour to change one, or several, of these factors will have to be addressed, but to do so will require a better understanding of them.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Environmental changes making handwashing easier and cheaper, such as tippy taps, could be helpful, though widespread use is unclear.

    “Environmental changes that make handwashing easier and cheaper, such as the introduction of simple water-saving technologies (eg, so-called tippy taps), could be helpful (although how their use could become widespread is unclear),”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Efforts continue to identify valid and simple indicators of hygiene practice.

    “Efforts are continuing to identify indicators of hygiene practice that are both valid and simple to collect.53, 54, 55”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [53] Biran, 2008, Comparing the performance of indicators of hand-washing practices in rural Indian households, Trop Med Int Health source
    • cites [54] Luby, 2008, Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh, Trop Med Int Health source
    • cites [55] Webb, 2006, A simple index to measure hygiene behaviours, Int J Epidemiol source

  • May combine two claims.

    Premisecitation

    Aunger and colleagues observed that habit was the most powerful determinant of handwashing in Kenya, followed by disgust, social norms, and cognitive plans to save money.

    “Aunger and colleagues68 observed that habit was the most powerful determinant of handwashing in Kenya, followed by several motives including disgust, and social norms, and cognitive plans to save money.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [68] Aunger, 2010, Three kinds of psychological determinants for hand-washing behaviour in Kenya, Soc Sci Med source

  • May combine two claims.

    Premisecitation

    Low-income groups face the highest risk of death from diarrhoeal disease and have fewer resources for hygiene.

    “the low-income sections of society, which are at greatest risk of death from diarrhoeal disease and have fewer resources to commit to hygiene.80”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [80] Schmidt, 2009, Determinants of handwashing practices in Kenya: the role of media exposure, poverty and infrastructure, Trop Med Int Health source

  • May combine two claims.

    Premisecitation

    It is unknown how long changes in hygiene behaviour persist or what investment is needed to maintain gains in a population.

    “Even when we are successful in changing hygiene behaviours we still do not know how persistent such changes are,11, 12 or the sort of investment that is needed to maintain the gains in a given population.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [11] Curtis, 2003, Effect of washing hands with soap on diarrhoea risk in the community: a systematic review, Lancet Infect Dis source
    • cites [12] Ejemot, 2008, Hand washing for preventing diarrhoea, Cochrane Database Syst Rev source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    More diverse and properly evaluated programmes will build knowledge about what best changes persistent habitual behaviours.

    “Because there are many different ways to promote hygiene, having more diverse and properly evaluated programmes will build a body of knowledge as to what works best in changing these persistent habitual behaviours.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    If programmes succeed in making hygienic habits routine across all societies, hygiene will become a foundation stone of global health.

    “If these programmes are successful in leading the members of all societies to adopt hygienic habits as a matter of course, then hygiene will be able to take its rightful place as one of the foundation stones of global health.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The community health club method in Zimbabwe significantly altered hygiene behaviour and created rural demand for sanitation.

    “The innovative method of community health clubs used in Zimbabwe significantly changed hygiene behaviour and built rural demand for sanitation.76”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [76] Waterkeyn, 2005, Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe, Soc Sci Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The authors also searched reference lists of relevant articles and contacted authors and experts to identify further articles.

    “We searched the reference lists of relevant articles and contacted authors and experts for further identification of articles.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    The authors searched Medline from 1970 to 2009 without language restriction, using specified search terms.

    “We searched Medline, from 1970 to 2009, regardless of language, using the search terms “[diarrh(o)ea AND hygiene]”, “[respiratory AND hygiene]”, “[food AND hygiene]”, “[pneumonia AND hygiene]”, “[stool AND disposal]”, “[waste AND hygiene]”, and “[animal faeces AND diarrh(o)ea]”.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Procter & Gamble's Safeguard brand has provided one-on-one school-based handwashing education to 35 million children and plans to reach 100 million more by 2012.

    “Procter & Gamble and its Safeguard brand has reached 35 million children with one-on-one, school-based handwashing education and is planning to reach 100 million more by 2012.8”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Kaufman, 1997, Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race, Epidemiology

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    In Makoni District, 14 trainers held 1244 health sessions, involving 11,450 club members at an average cost of US$0.21 per beneficiary.

    “In 1 year in Makoni District, 1244 health sessions were held by 14 trainers, costing an average of US$0·21 per beneficiary and involving 11 450 club members.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [76] Waterkeyn, 2005, Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe, Soc Sci Med source

  • May combine two claims.

    Interpretationnone given

    Without accurate measurement of hygiene behaviour changes, the effectiveness of interventions in trials and the delivery of behaviour change in programmes cannot be measured.

    “If we cannot accurately measure changes in hygiene behaviour we cannot measure the effectiveness of interventions in trials or evaluate the delivery of behaviour change in programmes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Other promising approaches, such as establishing hygiene habits in schools, are thought to be effective.

    “Other promising approaches, such as trying to establish hygiene habits in schools, are thought to be effective.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Once hygiene becomes established, improvements in behaviour will be truly sustainable.

    “Once hygiene is established, improvements in behaviours will be truly sustainable.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    If hygiene promotion in emerging markets is good business for private companies, improving sales and reputation, it could produce sustained long-term public health improvements, as occurred in developed countries.

    “If promoting hygiene in emerging markets makes good business sense to private companies, because they can improve sales and enhance their reputations, this could lead to sustained long-term improvements in public health, as it has in developed countries.9”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Wood, 2008, Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study, BMJ source

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    Food hygiene has the strongest case for being addressed first.

    “Food hygiene has the best claim to be tackled first, but all of the hygiene practices we have discussed have been neglected relative to the efforts for malaria or HIV research.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S4 (based).

    Premisecitation

    Hygiene promotion is the most cost-effective way to prevent disease in developing countries.

    “If hygiene promotion is truly the most cost-effective intervention for preventing disease in developing countries,1”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Jamieson, 2006

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Direct observation is cumbersome and intrusive.

    “simple questionnaire surveys give overestimates of behaviours such as handwashing, whereas direct observation is cumbersome and intrusive, and technological fixes, such as Smart Soap (containing accelerometers that record usage) have drawbacks too.14”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Luby, 2005, Effect of handwashing on child health: a randomised controlled trial, Lancet source

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationnone given

    Available information strongly indicates a need to improve handwashing, stool disposal, and food hygiene, especially during weaning.

    “Though the evidence base is far from complete, the information we do have strongly suggests a need to improve handwashing behaviour, stool disposal practices, and food hygiene in particular when weaning.”
    Quote in the paperSubstantial claim
63 of 63

  • The authors state this as an assumption.

    The handwashing data from the 11-country article and the Bangladesh survey are a good guide to handwashing with soap at key moments in developing countries.

    “If these figures are a good guide, less than one in six children in developing countries is protected from disease by handwashing with soap at key moments.”

  • The paper relies on this without support.

    Most sanitation and water supply programme implementers seek to improve hygiene alongside hardware but rarely have the resources and professional support to do this effectively.

    “Although most sanitation and water supply programme implementers seek to improve hygiene alongside hardware, they rarely have the resources and professional support needed to do this effectively.”

  • The paper relies on this without support.

    Too few health professionals are engaged in programmes to promote hygiene.

    “Health professionals recognise the need for better hygiene, but too few are actually engaged in programmes to promote it.”

  • The authors state this as an assumption.

    The true effect of hygiene promotion on disease in low-income settings may be smaller than studies suggest.

    “Even if the true effect on disease in low-income settings is smaller than studies suggest, hygiene improvements will likely have an effect on disease control at large scale.”

  • The paper relies on this without support.

    The standard approach to hygiene promotion has until recently been educational.

    “The standard approach to hygiene promotion, whether through schools, clinics, or health outreach programmes, has, until recently, been educational.”

  • The paper relies on this without support.

    Knowledge about possible long-term health effects does not necessarily translate into practice.

    “However, knowledge about possible long-term health effects does not necessarily translate into practice.”

  • The paper relies on this without support.

    PHAST has become the predominant model among non-government organisations in the past two decades.

    “In the past two decades an approach known as PHAST (participatory hygiene and sanitation transformation) has become the predominant model among non-government organisations.”

  • The paper relies on this without support.

    PHAST is mostly an educational approach, heavily reliant on trained facilitators, and difficult to implement on a large scale.

    “Although it is an imaginative attempt to involve communities in solving their own hygiene problems, PHAST is mostly an educational approach, is heavily reliant on the skills of trained facilitators, and is difficult to implement on a large scale.”

  • The paper relies on this without support.

    There are no rigorously collected data to support the effectiveness of PHAST programmes.

    “There are no rigorously collected data to support the effectiveness of PHAST programmes”

  • The paper relies on this without support.

    Some evidence from Tanzania and Uganda indicates that PHAST has limited effect on hygiene behaviour.

    “some evidence from Tanzania and Uganda indicates that the approach has limited effect on hygiene behaviour.”

  • The paper relies on this without support.

    Evidence of effect of school hygiene programmes is scarce.

    “Although evidence of effect is scarce”

  • The paper relies on this without support.

    The Global Public–Private Partnership for Handwashing with Soap has been building coalitions and national programmes in over 17 developing countries.

    “the Global Public–Private Partnership for Handwashing with Soap (PPP-HW) has been building coalitions and national programmes in over 17 developing countries.”

  • The paper relies on this without support.

    Good preliminary results were achieved after 1 year of programme activities in Ghana.

    “Good preliminary results were achieved after 1 year of programme activities in Ghana”

  • The paper relies on this without support.

    The PPP-HW model is convincing and innovative enough to have attracted substantial funds.

    “the model is convincing and innovative enough to have attracted substantial funds”

  • The paper relies on this without support.

    Questions about the effectiveness of PPP-HW remain.

    “but questions about effectiveness remain.”

  • The paper relies on this without support.

    In Ghana, Peru, and Senegal public health authorities and soap companies were not always easy bedfellows.

    “In Ghana, Peru, and Senegal public health authorities and soap companies were not always easy bedfellows”

  • The paper relies on this without support.

    National partnerships can be hard to sustain for longer than just one campaign.

    “national partnerships can be hard to sustain for longer than just one campaign.”

  • The paper relies on this without support.

    Gathering rigorous public domain evidence about the effectiveness of large-scale handwashing promotion efforts is proving challenging.

    “gathering such data is proving challenging, especially when interventions cannot be centrally controlled because they depend on the goodwill of various partners.”

  • The paper relies on this without support.

    Unilever has made handwashing part of the social mission of the Lifebuoy brand and has pledged to bring handwashing to one billion people by 2012.

    “Unilever, for example, has made handwashing part of the social mission of the Lifebuoy brand and has pledged to bring handwashing to one billion people by 2012.”

  • The paper relies on this without support.

    Local soap companies such as GeTrade in Ghana are also contributing their efforts.

    “Local soap companies such as GeTrade in Ghana are also contributing their efforts.”

  • The paper relies on this without support.

    Far more is known about hygiene now than a decade ago.

    “Far more is known about hygiene now than a decade ago.”

  • The paper relies on this without support.

    Hygiene features seldom in international public health efforts.

    “hygiene features so seldom in international public health efforts.”

  • The paper relies on this without support.

    Health workers will continue to use outdated methods and health education approaches that are demotivating because they are ineffective.

    “otherwise they will continue to use outdated methods and health education approaches that are demotivating because they are ineffective.”

  • The paper relies on this without support.

    We know enough to act now, but gaps in our knowledge exist.

    “although we know enough to act now, gaps in our knowledge exist.”

  • The paper relies on this without support.

    Investment in hygiene still remains low.

    “although investment still remains low”

  • The paper relies on this without support.

    The topic of hygiene is moving up the political agenda.

    “the topic of hygiene is moving up the political agenda.”

  • The paper relies on this without support.

    Inspired advocacy events, such as the Global Handwashing Day organised by the Global PPP-HW, have enhanced the global profile of hygiene.

    “Inspired advocacy events, such as the Global Handwashing Day organised by the Global PPP-HW, have enhanced the global profile of hygiene.”

  • The paper relies on this without support.

    Creating the framework for policy building is challenging given competition for attention in the relevant ministries, their limited human and logistic resources, and shortage of skills.

    “Creating this framework is challenging given competition for attention in the relevant ministries, their limited human and logistic resources, and shortage of skills.”

  • The paper relies on this without support.

    These problems are often worst in the remote and poverty-stricken areas that would benefit most from improved hygiene.

    “These problems are often worst in the remote and poverty-stricken areas that would benefit most from improved hygiene.”

  • The paper relies on this without support.

    Training in up-to-date methods of communication is lacking at all levels in health ministries.

    “Training in up-to-date methods of communication is lacking at all levels in health ministries.”

  • The paper relies on this without support.

    Funding such skills development has not been a priority for donors in recent years.

    “funding such skills development has, unfortunately, not been a priority for donors in recent years.”

  • The paper relies on this without support.

    Marketing expertise from the private sector has been helping to fill the skills gap.

    “Marketing expertise from the private sector has been helping to fill the skills gap”

  • The paper relies on this without support.

    The interface between programmes and health research is problematic.

    “The interface between programmes and health research is also problematic”

  • The paper relies on this without support.

    Local universities are the obvious institutions for designing and evaluating hygiene promotion programmes, but very few have that capacity at present.

    “Local universities are the obvious institutions for designing and evaluating hygiene promotion programmes, but very few have that capacity at present.”

  • The paper relies on this without support.

    Large-scale engineering programmes are rarely equipped to handle the behavioural side of development.

    “large-scale engineering programmes are rarely equipped to handle what they call the software (ie, the behavioural) side of development.”

  • The paper relies on this without support.

    Decentralised authorities and non-government organisations are often willing to implement hygiene promotion, but rarely have the specific expertise or capacity to develop the approaches themselves.

    “Such agencies are often willing to implement hygiene promotion, but rarely have the specific expertise or capacity to develop the approaches themselves.”

  • The paper relies on this without support.

    Simple technologies, such as water-saving taps, nappies, potties, and child-friendly toilets, can help families to live more hygienically.

    “simple technologies, such as water-saving taps, nappies, potties, and child-friendly toilets, can help families to live more hygienically”

  • The paper relies on this without support.

    Little effort has been made to develop and market hygiene-helping products that are appropriate for the consumers with low income.

    “little effort has been made to develop and market hygiene-helping products that are appropriate for the consumers with low income.”

  • The paper relies on this without support.

    All of the hygiene practices we have discussed have been neglected relative to the efforts for malaria or HIV research.

    “all of the hygiene practices we have discussed have been neglected relative to the efforts for malaria or HIV research.”

  • The paper relies on this without support.

    There is no evidence to indicate whether the practice of using animal dung to smooth floors and walls is injurious to family health.

    “there is no evidence to indicate whether the practice of using animal dung to smooth floors and walls (common in Asia) is injurious to family health.”

  • The paper relies on this without support.

    Most schools in developing countries still do not have sanitation and hygiene facilities.

    “most schools in developing countries still do not have sanitation and hygiene facilities”

  • The paper relies on this without support.

    Health centres, hospitals, maternity facilities, workplaces, and public institutions still cannot offer water and soap to their users.

    “health centres, hospitals, maternity facilities, workplaces, and public institutions still cannot offer water and soap to their users.”

  • The paper relies on this without support.

    Birth attendants and outreach workers are not always trained to wash hands with soap and do not systematically promote handwashing and hygiene to mothers.

    “birth attendants and outreach workers are not always trained to wash hands with soap and do not systematically promote handwashing and hygiene to mothers.”

  • The paper relies on this without support.

    In the next 5–10 years we have a window of opportunity to develop the high impact programmes which will bring about mass scale changes.

    “In the next 5–10 years we have a window of opportunity to develop the high impact programmes which will bring about mass scale changes.”
44 of 44

Cites

Flagged first, then by citations

5 of the 83 references couldn’t be matched to a known paper.

Research works printed but not linked: 5

  1. Scott, 2007, Marketing hygiene behaviours: the impact of different communications channels on reported handwashing behaviour of women in Ghana, Health Educ Res, 22, 225
  2. Curtis, 2003, Effect of washing hands with soap on diarrhoea risk in the community: a systematic review, Lancet Infect Dis, 3, 275, 10.1016/S1473-3099(03)00606-6 · DOI · Paper page
  3. Biran, 2005, Formative research for hygiene promotion in Kyrgyzstan, Health Pol Plan, 20, 213, 10.1093/heapol/czi024 · DOI
  4. Curtis, 2001, Evidence for behaviour change following a hygiene promotion programme in West Africa, Bull World Health Organ, 79, 518
  5. Bolam, 1998, The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled trial, BMJ, 316, 805, 10.1136/bmj.316.7134.805 · DOI · Paper page

Cited by

Sorted by citations

Related

Authors
Curtis, V., Schmidt, W., Luby, S., Florez, R., Touré, O., & Biran, A.
Affiliations
  • London School of Hygiene & Tropical Medicine (GB)
  • International Centre for Diarrhoeal Disease Research (BD)
  • Ministère de la Santé et de l'Hygiène Publique (ML)
Corresponding author
Curtis, Val
ORCID
Venue
The Lancet Infectious Diseases
Publisher
Elsevier BV
Published
2011-04
Volume
11
Issue
4
Pages
312-321
ISSN
1473-3099 (ISSN-L)
DOI
10.1016/s1473-3099(10)70224-3
PMC
PMC7106354
OpenAlex
W2166713712
Cited by
228
References
83
Citations by year
2026: 8 · 2025: 17 · 2024: 6 · 2023: 10 · 2022: 13 · 2021: 20 · 2020: 28 · 2019: 13 · 2018: 10 · 2017: 18 · 2016: 15 · 2015: 15 · 2014: 16 · 2013: 24 · 2012: 14
FWCI
2.09
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet Infectious Diseases (publishedVersion, public-domain)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
  • Life Sciences › Agricultural and Biological Sciences › Food Science › Food Safety and Hygiene
  • Health Sciences › Medicine › Infectious Diseases › Infection Control in Healthcare
Keywords
hygiene promotion, hand washing, hygiene behaviour change, food hygiene, social norms, water and sanitation, infectious disease prevention, developing countries
MeSH terms
Communicable Disease Control, Communicable Diseases, Humans, Hygiene, Public Health

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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