Hygiene promotion in Haiti: can we rule out negative effects on handwashing behavior?

Abstract

Unsafe water, poor sanitation, and insufficient hygiene are leading causes for high diar-rheal mortality rates in developing countries. In emergency situations, such as after natural disasters, the danger of diarrheal diseases becomes even greater. This was the case in Haiti, which was struck by an earthquake in January 2010. The immense devastation further worsened Haiti’s level of sanitation and hygiene leading to a cholera outbreak in October 2010. Handwashing with soap is the most effective prevention against diarrheal diseases, including cholera. Therefore, amongst other emergency relief work, numerous relief organi-zations conducted hand washing promotions all around the country to improve hand washing practice. In spite of these efforts, the epidemic could hardly be kept at bay until today. In the future, aid could be administered more effectively when we gain deeper understanding about which health promotion strategies work best in changing hygiene behavior. In an evaluative field study on hygiene promotion in Haiti, Contzen and Mosler (in preparation) examined the relationships between different promotion activities, behavioral factors, and hand washing behavior. They found that the experience of the promotion types focus groups, stickers, posters, or paintings, hygiene songs, special hygiene days, and home visits was associated with lower hand washing frequencies. Because the findings by Contzen and Mosler were based on correlative data we cannot assume causality. Self-selection effects or the influence of third variables might be responsible for the negative associations. We used an exploratory approach to analyze in-depth the negative associations regarding three aspects. First, we assessed whether the negative associations could be explained by self-selection effects on the basis of socio-demographic characteristics. Second, we tested whether the participants’ attitudes towards the promotions accounted for the negative associations. Persons with a critical attitude towards health promotions might have preferably chosen the mentioned pro-motion types. Third, we looked at interaction effects with promotion types that were positively associated with hand washing, namely material distributions and radio spots, to check whether the negative associations could be explained by interactions with these promotions. Non-parametric statistical techniques were used because of non-normally distributed data. The results did not point to any self-selection effects based on socio-demographic character-istics. Yet, persons who had a very positive attitude towards the promotions were not affected by any negative influence of the mentioned promotion types. Moreover, material distributions had a mitigating effect, because, among persons who experienced material distributions, most of the mentioned promotion types were not negatively associated with hand washing. All in all, as the negative associations could not be fully explained by self-selection or third variables, a causal negative influence of the respective promotion types on hand washing cannot be ruled out. Our findings highlight the importance of future research to verify which single or combined promotion strategies are effective, which ones are not or even counter-productive, and by which mechanisms they are so.