Hygiene Problems Impacting Health in Developing Communities

Chapter 2

Abstract

challenges

9

1. Introduction

Countries

Save Kumwenda

Challenges to Hygiene

Improvement in Developing

promoting gender equity, and enhancing youth involvement.

suggests possible solutions to these problems.

1.1 What are developing countries?

Hygiene is defined as conditions or practices conducive to maintaining health and preventing disease. Hygiene has been shown to reduce diarrheal diseases and assist to improve social outcomes in the community. Improving hygiene faces several problems especially in countries with low income per capita of population. Currently, many developing countries already struggle to cope with consistent water shortages and rapid urbanization causing more pressure to limited resources which in turn result in poor hygienic practices in the communities. The common types of hygiene include personal hygiene, water hygiene, food hygiene, and hygiene during waste handling. Different nongovernmental and governmental organizations face different challenges in achieving high levels of hygiene in communities. Some of these challenges include poverty, lack of political commitment, lack of full community participation, inadequate gender inclusion, inadequate data, lack of coordination among actors, and behavioral issues. To reduce these challenges, several measures have been proposed including community empowerment, pushing for equitable access to hygiene needs, advocating for political commitment,

Keywords: hygiene, hand washing, soap, developing countries, communities and

This chapter defines hygiene in the context of developing countries. It then outlines the various major types of hygiene before tackling the challenges in the implementation of projects aimed at hygiene improvement. The chapter then

There are different definitions of developing countries; however, the broad definition is that; this is a term often used to refer to countries with medium to low human development index (HDI) or sometimes the gross domestic product (GDP) is used. These countries are mainly found in Africa, Asia, and some in South America that generally lack a high degree of industrialization, infrastructure and other capital investment, sophisticated technology, widespread literacy, and

## Chapter 2 Challenges to Hygiene Improvement in Developing Countries

Save Kumwenda

### Abstract

Hygiene is defined as conditions or practices conducive to maintaining health and preventing disease. Hygiene has been shown to reduce diarrheal diseases and assist to improve social outcomes in the community. Improving hygiene faces several problems especially in countries with low income per capita of population. Currently, many developing countries already struggle to cope with consistent water shortages and rapid urbanization causing more pressure to limited resources which in turn result in poor hygienic practices in the communities. The common types of hygiene include personal hygiene, water hygiene, food hygiene, and hygiene during waste handling. Different nongovernmental and governmental organizations face different challenges in achieving high levels of hygiene in communities. Some of these challenges include poverty, lack of political commitment, lack of full community participation, inadequate gender inclusion, inadequate data, lack of coordination among actors, and behavioral issues. To reduce these challenges, several measures have been proposed including community empowerment, pushing for equitable access to hygiene needs, advocating for political commitment, promoting gender equity, and enhancing youth involvement.

Keywords: hygiene, hand washing, soap, developing countries, communities and challenges

#### 1. Introduction

This chapter defines hygiene in the context of developing countries. It then outlines the various major types of hygiene before tackling the challenges in the implementation of projects aimed at hygiene improvement. The chapter then suggests possible solutions to these problems.

#### 1.1 What are developing countries?

There are different definitions of developing countries; however, the broad definition is that; this is a term often used to refer to countries with medium to low human development index (HDI) or sometimes the gross domestic product (GDP) is used. These countries are mainly found in Africa, Asia, and some in South America that generally lack a high degree of industrialization, infrastructure and other capital investment, sophisticated technology, widespread literacy, and

advanced living standards among their population as a whole [1, 2]. In short, these are countries with low income per capita of population that are trying to improve their conditions through industrialization [3]. In addition, the United Nations (UN) describes a developing country as a country with a relatively low standard of living, undeveloped industrial base, and moderate to low HDI, with a high employment share of 60–70% in agriculture [4]. Developing countries also have low life expectancies [5, 6]. However, regardless of the low income in developing countries, there is high population growth in these countries. It is this high population growth in developing countries that is seriously outstripping the capacity of most countries to provide adequate services for their citizens [5].

• Waste handling hygiene relates to how solid, liquid, and gas wastes are handled from generation, collection, storage, transportation, and disposal to prevention

Hygiene can be practiced at personal, domestic, and community levels [14].

The greatest benefit of practicing hygiene is the reduction in disease transmis-

Systematic reviews done from 1997 to 2010 have shown that hand washing with soap reduced diarrhea by either 32 or 48%. Furthermore, hand washing with soap including water supply and sanitation has been shown to reduce undernutrition by 50% [19]. In Kenya, water, sanitation, and hygiene intervention showed a reduction of 58% in absenteeism for girls [21]. Apart from health benefits and school absenteeism, hygiene has other social benefits including boosting confidence and status [19]. It should, however, be noted that the impact of hygiene cannot be easily evident in short term projects, and it required time for it to show significant impact

Hand washing with soap at critical moments, such as after visiting a toilet, before cooking, and after helping a child defecate, can prevent infectious diseases by interrupting the transmission of infectious agents. Evidence suggests that hand washing with soap reduces the risk of diarrhea by 47% [23, 24], acute lower respiratory infections by up to 34% [25], and soil-transmitted helminths by 55% [26]. Hand washing with soap has been recognized as one of the most cost-effective health interventions to reduce the burden of disease [27]. Yet, only 19% of the global population is estimated to wash their hands with soap after using sanitation

sion and improved health. The maximum benefits of hygiene are achieved, if improvements in hygiene are concurrently made with improvements in the food industry, water supply, and sanitation coupled with other interventions such as improved nutrition [14]. Good hygiene practices are among the essentials of the survival and development of children. Without hygiene, the lives of millions of people especially children and the vulnerable populations would be at risk of suffering from water, sanitation, and hygiene-related diseases which are one of the leading causes of death among children, despite being preventable [15]. In 2015, diarrhea was the leading cause of death among all ages. The most affected were children under the age of five where it claimed the lives of more than 499,000 children each day [16]. Most of the diarrhea is attributed to poor water, sanitation, and hygiene practices. Children in developing countries are the worst affected as they experience about 4–5 episodes of diarrhea each year [17–19]. Diarrhea is caused by fecal-oral transmission, whereby one ingests feces directly through contaminated hands or indirectly through contaminated food and water [20]. The organisms that cause diarrhea include bacteria, viruses, protozoa, and helminths [19]. This might be through contaminated hands when ingesting food or contaminated water. Hands (mainly fingers) can directly or indirectly be contaminated with feces of one self or of another. Contamination of the hands during activities such as defecation and changing/washing of a child's bottom facilitates the transmission of infections. Hand washing with soap is one of the most important hygiene behavior in disease transmission reduction and promotion of good health. In 2012, it was found that 35.3% of all the total deaths from diarrhea were due to poor hand

1.4 Importance of hygiene to health in developing countries

contamination of the environment.

DOI: http://dx.doi.org/10.5772/intechopen.80355

Challenges to Hygiene Improvement in Developing Countries

hygiene [19].

especially on health [22].

1.5 Hand washing

11

Currently, many developing countries already struggle to cope with consistent water shortages and they lack adequate water infrastructure. High population growth and rapid urbanization cause more pressure to these limited water resources which in turn results in poor access to improved water source and limits hygienic practices in the communities, as these hygienic practices highly depend on the availability of safe water [6]. Hygiene causes a global health challenge especially in the developing world even though thus far, hygiene has been barely prioritized on the international development agenda despite the fact that a hygienic behavior such as hand washing with soap could save lives of people annually [6, 7].

#### 1.2 What is hygiene?

According to Oxford English Dictionary, 2018, the word "hygiene" is defined as "conditions or practices conducive to maintaining health and preventing disease, especially through cleanliness" [8].

The World Health Organization (WHO) and other studies have similar definitions as the Oxford English Dictionary, and they define hygiene as the concept of cleaning and any practice aimed at maintaining health and preventing the spread of diseases [9, 10]. Other literatures define it as the science of preventive medicine and preservation of health through cleanliness [11]. However, it should be noted that the term cleanliness is not the same as hygiene. Hygiene is far more than just cleanliness because cleanliness mostly involves the removal of dirt, wastes or unwanted things from the surface of objects using detergents and other necessary equipment. On the other hand, hygiene practices focus on the prevention of disease through the use of cleaning as one of the several inputs [12, 13]. Hygiene can be achieved through cleanliness and not vice versa. All disease control interventions to a greater extent rely on hygiene for them to achieve their goal.

#### 1.3 Types of hygiene

Hygiene is applied in different areas with the aim of prevention of disease transmission and promoting health. The common types of hygiene include:


advanced living standards among their population as a whole [1, 2]. In short, these are countries with low income per capita of population that are trying to improve their conditions through industrialization [3]. In addition, the United Nations (UN) describes a developing country as a country with a relatively low standard of living, undeveloped industrial base, and moderate to low HDI, with a high employment share of 60–70% in agriculture [4]. Developing countries also have low life expectancies [5, 6]. However, regardless of the low income in developing countries, there is high population growth in these countries. It is this high population growth in developing countries that is seriously outstripping the capacity of most countries to

Currently, many developing countries already struggle to cope with consistent water shortages and they lack adequate water infrastructure. High population growth and rapid urbanization cause more pressure to these limited water resources which in turn results in poor access to improved water source and limits hygienic practices in the communities, as these hygienic practices highly depend on the availability of safe water [6]. Hygiene causes a global health challenge especially in the developing world even though thus far, hygiene has been barely prioritized on the international development agenda despite the fact that a hygienic behavior such

According to Oxford English Dictionary, 2018, the word "hygiene" is defined as "conditions or practices conducive to maintaining health and preventing disease,

The World Health Organization (WHO) and other studies have similar definitions as the Oxford English Dictionary, and they define hygiene as the concept of cleaning and any practice aimed at maintaining health and preventing the spread of diseases [9, 10]. Other literatures define it as the science of preventive medicine and preservation of health through cleanliness [11]. However, it should be noted that the term cleanliness is not the same as hygiene. Hygiene is far more than just cleanliness because cleanliness mostly involves the removal of dirt, wastes or unwanted things from the surface of objects using detergents and other necessary equipment. On the other hand, hygiene practices focus on the prevention of disease through the use of cleaning as one of the several inputs [12, 13]. Hygiene can be achieved through cleanliness and not vice versa. All disease control interventions to

Hygiene is applied in different areas with the aim of prevention of disease transmission and promoting health. The common types of hygiene include:

• Personal hygiene includes taking care on one's body and clothes. Personal hygiene encompasses oral hygiene, hand hygiene, hair hygiene, mouth hygiene, and menstrual hygiene including any form of hygiene relating to a

• Water hygiene involves the collection, transportation, storage, and use of

• Food hygiene is the practical process of ensuring that food is fit to eat. It is

as hand washing with soap could save lives of people annually [6, 7].

a greater extent rely on hygiene for them to achieve their goal.

what the food handler does to prevent contamination.

provide adequate services for their citizens [5].

The Relevance of Hygiene to Health in Developing Countries

1.2 What is hygiene?

1.3 Types of hygiene

personal body.

10

water without contaminating it.

especially through cleanliness" [8].

• Waste handling hygiene relates to how solid, liquid, and gas wastes are handled from generation, collection, storage, transportation, and disposal to prevention contamination of the environment.

Hygiene can be practiced at personal, domestic, and community levels [14].

#### 1.4 Importance of hygiene to health in developing countries

The greatest benefit of practicing hygiene is the reduction in disease transmission and improved health. The maximum benefits of hygiene are achieved, if improvements in hygiene are concurrently made with improvements in the food industry, water supply, and sanitation coupled with other interventions such as improved nutrition [14]. Good hygiene practices are among the essentials of the survival and development of children. Without hygiene, the lives of millions of people especially children and the vulnerable populations would be at risk of suffering from water, sanitation, and hygiene-related diseases which are one of the leading causes of death among children, despite being preventable [15]. In 2015, diarrhea was the leading cause of death among all ages. The most affected were children under the age of five where it claimed the lives of more than 499,000 children each day [16]. Most of the diarrhea is attributed to poor water, sanitation, and hygiene practices. Children in developing countries are the worst affected as they experience about 4–5 episodes of diarrhea each year [17–19]. Diarrhea is caused by fecal-oral transmission, whereby one ingests feces directly through contaminated hands or indirectly through contaminated food and water [20]. The organisms that cause diarrhea include bacteria, viruses, protozoa, and helminths [19]. This might be through contaminated hands when ingesting food or contaminated water. Hands (mainly fingers) can directly or indirectly be contaminated with feces of one self or of another. Contamination of the hands during activities such as defecation and changing/washing of a child's bottom facilitates the transmission of infections. Hand washing with soap is one of the most important hygiene behavior in disease transmission reduction and promotion of good health. In 2012, it was found that 35.3% of all the total deaths from diarrhea were due to poor hand hygiene [19].

Systematic reviews done from 1997 to 2010 have shown that hand washing with soap reduced diarrhea by either 32 or 48%. Furthermore, hand washing with soap including water supply and sanitation has been shown to reduce undernutrition by 50% [19]. In Kenya, water, sanitation, and hygiene intervention showed a reduction of 58% in absenteeism for girls [21]. Apart from health benefits and school absenteeism, hygiene has other social benefits including boosting confidence and status [19]. It should, however, be noted that the impact of hygiene cannot be easily evident in short term projects, and it required time for it to show significant impact especially on health [22].

#### 1.5 Hand washing

Hand washing with soap at critical moments, such as after visiting a toilet, before cooking, and after helping a child defecate, can prevent infectious diseases by interrupting the transmission of infectious agents. Evidence suggests that hand washing with soap reduces the risk of diarrhea by 47% [23, 24], acute lower respiratory infections by up to 34% [25], and soil-transmitted helminths by 55% [26]. Hand washing with soap has been recognized as one of the most cost-effective health interventions to reduce the burden of disease [27]. Yet, only 19% of the global population is estimated to wash their hands with soap after using sanitation

#### The Relevance of Hygiene to Health in Developing Countries

facility or handling children's excreta [28]. Hand washing facilities close to toilet are important if people are to wash hands after using the toilet facility (Figure 1).

Hand washing should not only involve getting the hands wet or a quick rinse under a tap or in a bowl, but it should rather be a hygienic hand washing, where there is removal of microorganisms from contaminated hand surfaces using soap or detergent. Hand washing with nonantibacterial soap and clean water was found to be more effective than just using water [31]. For most of the people in the rural communities of the developing countries, they cannot afford to get soap for hand washing. Nonetheless, alternatives such as wood ash and mud have been found to be better than using only water [32]. However, it should be noted that communities which can afford soap should be encouraged not to use ash and mud because of their varying abilities to remove germs from hands and other risks than may come due their use. It should be further noted that hand washing should involve the use of running water that carries away the microorganisms unlike dipping in a bowl. Washing in the same bowl may be a way of transmitting pathogens that are found in hands [33]. Clean sand with water or local seeds such as indod (Lemma's plant) can also be used as an alternative just as wood-ash, which rubs off both the dirt and the smells [34]. The correct hand washing

procedure according to WHO [35], includes the following 10 modified steps:

Step three Rub right palm over left dorsum with interlocked fingers and vice versa

Step six Make rotational rubbing of left thumb clasped in right palm and vice versa

Step five Rub backs of fingers to opposing palms with fingers interlocked

Step eight Rinse hands well with clean running water or pour from jug

Step ten Use towel or back of hand depending on design to turn off tap

Step two Rub hands palm to palm

dislodged [35].

risk of disease transmission [37].

1.6 Menstrual hygiene

13

not have adequate access to piped water [38].

Step four Rub palm to palm with fingers interlocked

Challenges to Hygiene Improvement in Developing Countries

DOI: http://dx.doi.org/10.5772/intechopen.80355

in left palm and vice versa

Step one First wetting the hands with clean water and apply enough soap to cover the hand surfaces

Step seven Perform rotational rubbing, backwards and forwards with clutched fingers of right hand

Step nine Dry hands thoroughly with a single use towel or dry in the air to avoid recontamination

Rubbing of hands should take approximately 20–30 s to make sure germs are

Hand washing with soap is also an important infection prevention tool in health facilities [36]. Daily works will involve many situations when people need to wash their hands, and sometimes people forget to wash their hands. However, it is of great importance to identify critical situations/times for hand washing. These are times, activities or incidents that indicate the possibility that pathogenic microorganisms are present on hand fingers and nail surfaces. Most people remember to wash hands after defecation than after doing other things that may equally have the

To encourage hand washing, there is need to locate the hand washing facilities in suitable places such as close to the latrine and/in the kitchen where they will be needed. These hand washing facilities should be provided with soap (or its alternative) and running water. In the absence of a tap, cans and plastic bottles can be used. These alternatives are mostly used in the rural areas where communities do

Another aspect of personal hygiene that greatly affects women and adolescent girls is menstrual hygiene. This is special care that is needed during the time of the

Good hygiene is of vital importance in Malawi due to the lack of basic sanitation in the country. Hygiene, for example, washing hands with soap after using a toilet may reduce the transmission of fecal-related diseases. Although, evidence of actual hand washing practice is scanty, but some studies done in rural areas of the country suggest that the actual practice of hand washing with soap (HWWS) at key times is between 3 and 18% but more likely on the low end of this scale, as responses tend to exaggerate actual and regular practice. Observations in Malawi and other countries show that HWWS promotion is undertaken as an ad hoc activity both at national and local level. Current efforts to promote good hygiene and HWWS, in particular, have not been sufficient to bring about mass behavior change on the scale that is needed. Efforts producing piecemeal village-by-village and pilot approaches have had some impact but nothing on a large or national scale has been attempted [29]. Our hands frequently get dirty during our normal activities, with microorganisms likely to attach to our hands along with the dirt. Hand hygiene, however, especially hand washing with soap plays a critical role in prevention of such transmissions, through hygienic hand washing. Soap helps remove dirt and microorganism from the hands. Global waters [30] in 2017 put coverage of hand washing facilities at 27% in Sub-Saharan Africa and below 50% in Africa. The critical times for hand washing with soap include:


Figure 1. Tippy tap close to toilet for hand washing in rural areas of Malawi.

#### Challenges to Hygiene Improvement in Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.80355

facility or handling children's excreta [28]. Hand washing facilities close to toilet are important if people are to wash hands after using the toilet facility (Figure 1).

The Relevance of Hygiene to Health in Developing Countries

below 50% in Africa. The critical times for hand washing with soap include:

a. Before cooking food

b.Before eating food

Figure 1.

12

c. After visiting a toilet

d.After cleaning or touching dirt

e. After changing baby nappies

Tippy tap close to toilet for hand washing in rural areas of Malawi.

Good hygiene is of vital importance in Malawi due to the lack of basic sanitation in the country. Hygiene, for example, washing hands with soap after using a toilet may reduce the transmission of fecal-related diseases. Although, evidence of actual hand washing practice is scanty, but some studies done in rural areas of the country suggest that the actual practice of hand washing with soap (HWWS) at key times is between 3 and 18% but more likely on the low end of this scale, as responses tend to exaggerate actual and regular practice. Observations in Malawi and other countries show that HWWS promotion is undertaken as an ad hoc activity both at national and local level. Current efforts to promote good hygiene and HWWS, in particular, have not been sufficient to bring about mass behavior change on the scale that is needed. Efforts producing piecemeal village-by-village and pilot approaches have had some impact but nothing on a large or national scale has been attempted [29]. Our hands frequently get dirty during our normal activities, with microorganisms likely to attach to our hands along with the dirt. Hand hygiene, however, especially hand washing with soap plays a critical role in prevention of such transmissions, through hygienic hand washing. Soap helps remove dirt and microorganism from the hands. Global waters [30] in 2017 put coverage of hand washing facilities at 27% in Sub-Saharan Africa and

Hand washing should not only involve getting the hands wet or a quick rinse under a tap or in a bowl, but it should rather be a hygienic hand washing, where there is removal of microorganisms from contaminated hand surfaces using soap or detergent. Hand washing with nonantibacterial soap and clean water was found to be more effective than just using water [31]. For most of the people in the rural communities of the developing countries, they cannot afford to get soap for hand washing. Nonetheless, alternatives such as wood ash and mud have been found to be better than using only water [32]. However, it should be noted that communities which can afford soap should be encouraged not to use ash and mud because of their varying abilities to remove germs from hands and other risks than may come due their use. It should be further noted that hand washing should involve the use of running water that carries away the microorganisms unlike dipping in a bowl. Washing in the same bowl may be a way of transmitting pathogens that are found in hands [33]. Clean sand with water or local seeds such as indod (Lemma's plant) can also be used as an alternative just as wood-ash, which rubs off both the dirt and the smells [34]. The correct hand washing procedure according to WHO [35], includes the following 10 modified steps:


Rubbing of hands should take approximately 20–30 s to make sure germs are dislodged [35].

Hand washing with soap is also an important infection prevention tool in health facilities [36]. Daily works will involve many situations when people need to wash their hands, and sometimes people forget to wash their hands. However, it is of great importance to identify critical situations/times for hand washing. These are times, activities or incidents that indicate the possibility that pathogenic microorganisms are present on hand fingers and nail surfaces. Most people remember to wash hands after defecation than after doing other things that may equally have the risk of disease transmission [37].

To encourage hand washing, there is need to locate the hand washing facilities in suitable places such as close to the latrine and/in the kitchen where they will be needed. These hand washing facilities should be provided with soap (or its alternative) and running water. In the absence of a tap, cans and plastic bottles can be used. These alternatives are mostly used in the rural areas where communities do not have adequate access to piped water [38].

#### 1.6 Menstrual hygiene

Another aspect of personal hygiene that greatly affects women and adolescent girls is menstrual hygiene. This is special care that is needed during the time of the month when women and girls experience their menstruation. This special care is needed to take care of the sanitary products that are used by the women. In the developing countries, not many women can afford to buy enough sanitary products such as disposable pads, tampons or menstrual cups. The women tend to use locally available clothes which they reuse, while others have been introduced to reusable pads [39, 40]. Nonetheless, regardless of the product used, women are supposed to change their sanitary products frequently, and for those that use reusable products, there is need for soap, clean water, and proper drying area for the reusable towels. Not only does poor menstrual hygiene causes bad odor, but it can further cause fungal infections, urinary tract infections (UTI), and reproductive tract infections (RTI) [41]. Women are further vulnerable to infertility when their menstrual hygiene practices are unhygienic, for example, not changing their sanitary towels frequently, lack of adequate cleaning of reusable products, and the use of unclean water for cleaning both their bodies and their sanitary towels. Good menstrual hygiene practice further involves proper disposal of sanitary materials, but this is a problem in most developing countries [42].

incorporate the approach in village and district plans for it to be sustainable. The weakness with the approach was that it did not emphasize much on hygiene behavior but rather on ownership of hygiene promoting facilities [46].

2. Challenges faced when implementing hygiene in developing nations

from local materials which are not durable (Figure 2).

Challenges to Hygiene Improvement in Developing Countries

DOI: http://dx.doi.org/10.5772/intechopen.80355

2.2 Lack of political commitments

Poverty is high in developing countries, most households spend less than a dollar a day, and these are classified as extremely poor [47]. This makes them prioritize income so that they buy food, clothes, and other immediate needs placing sanitation and hygiene low in the priority list. Most families struggle to find food, and to them getting food is enough than considering hygiene. Most families start prioritizing hygiene after they move up the development ladder especially when basics like food are no longer a problem [48]. Due to poverty, communities find it difficult to use the only available soap at a household for hand washing [32]. Similarly, hand washing facilities used after visiting a toilet are usually temporary and are made

Most of the hygiene initiatives are implemented by nongovernmental organizations (NGOs) and rarely by the government. Despite advocating for water sanitation and hygiene (WASH), there is not enough initiatives introduced by the government through relevant ministries (i.e., Ministry of Health and Ministry of Agriculture, Irrigation and Water Development in Malawi), to enhance hygiene

2.1 Poverty

Figure 2.

15

Hand washing facility at a toilet in rural Malawi.

#### 1.7 Domestic and community hygiene

While hygiene measures are taken at personal, domestic, and industrial levels, some can be done at a community level. Community members have a role to play in keeping their communities clean [14]. The members play a role to ensure a clean surrounding of their households, protecting the water sources, proper disposal of wastes (solid wastes and excreta), proper drainage for waste water, control of animal rearing, and hygiene of public places such as markets, schools, health facilities, and prayer areas (e.g., churches and mosques) [6, 12, 13].

Clean compounds in communities should be encouraged, as a single unhygienic house can affect the surrounding neighbors and increase the spread of disease. Presence of shrubs, lack of drainage, and poor waste management in households can act as breeding grounds for vectors, resulting in vector-borne diseases such as malaria, affecting a larger part of the community [14, 43]. Households should be properly ventilated to allow fresh air in the house as this would also reduce transmissions of infections such as flu [44].

Most markets in developing countries lack proper water resources, sanitation facilities, proper solid waste management, and drainage. However, in most of these markets, raw food such as fruits and vegetables are usually sprinkled with water, which is at most times unclean [13]. Such unhygienic practices poses a risk to the consumers, that is why it is encouraged that a market should have a proper water source, not only for cleaning the goods but also for the sellers, since they use the same water for drinking and cooking.

The Government of Malawi in a bid to improve sanitation and hygiene coverage adopted the open defecation free (ODF) and hand washing with soap (HWWS) strategies in 2011. The strategies were up to 2015. By 2015, the strategies had improved the percentage of the country's population practicing open defecation from 29 to 4% and access to improved sanitation increased from 29 to 41%. Hand washing with soap was also improved from less than 10 to 34% [45]. The government adopted Community Led Total Sanitation (CLTS) as a technique that was used to make sure communities are using toilets and also making sure all households own and use a hand washing facility after visiting a toilet. The approach has managed to increase toilet coverage and usage especially in rural areas by 96% as stated above. CLTS encourages the use of local resources to build sanitation and hygiene facilities, and its sustainability relies on the availability of these local resources. Since CLTS was being implemented as a project, there is a need to

incorporate the approach in village and district plans for it to be sustainable. The weakness with the approach was that it did not emphasize much on hygiene behavior but rather on ownership of hygiene promoting facilities [46].

## 2. Challenges faced when implementing hygiene in developing nations

#### 2.1 Poverty

month when women and girls experience their menstruation. This special care is needed to take care of the sanitary products that are used by the women. In the developing countries, not many women can afford to buy enough sanitary products such as disposable pads, tampons or menstrual cups. The women tend to use locally available clothes which they reuse, while others have been introduced to reusable pads [39, 40]. Nonetheless, regardless of the product used, women are supposed to change their sanitary products frequently, and for those that use reusable products, there is need for soap, clean water, and proper drying area for the reusable towels. Not only does poor menstrual hygiene causes bad odor, but it can further cause fungal infections, urinary tract infections (UTI), and reproductive tract infections (RTI) [41]. Women are further vulnerable to infertility when their menstrual hygiene practices are unhygienic, for example, not changing their sanitary towels frequently, lack of adequate cleaning of reusable products, and the use of unclean water for cleaning both their bodies and their sanitary towels. Good menstrual hygiene practice further involves proper disposal of sanitary materials, but this is a

While hygiene measures are taken at personal, domestic, and industrial levels, some can be done at a community level. Community members have a role to play in keeping their communities clean [14]. The members play a role to ensure a clean surrounding of their households, protecting the water sources, proper disposal of wastes (solid wastes and excreta), proper drainage for waste water, control of animal rearing, and hygiene of public places such as markets, schools, health facil-

Clean compounds in communities should be encouraged, as a single unhygienic

Most markets in developing countries lack proper water resources, sanitation facilities, proper solid waste management, and drainage. However, in most of these markets, raw food such as fruits and vegetables are usually sprinkled with water, which is at most times unclean [13]. Such unhygienic practices poses a risk to the consumers, that is why it is encouraged that a market should have a proper water source, not only for cleaning the goods but also for the sellers, since they use the

The Government of Malawi in a bid to improve sanitation and hygiene coverage adopted the open defecation free (ODF) and hand washing with soap (HWWS) strategies in 2011. The strategies were up to 2015. By 2015, the strategies had improved the percentage of the country's population practicing open defecation from 29 to 4% and access to improved sanitation increased from 29 to 41%. Hand washing with soap was also improved from less than 10 to 34% [45]. The government adopted Community Led Total Sanitation (CLTS) as a technique that was used to make sure communities are using toilets and also making sure all households own and use a hand washing facility after visiting a toilet. The approach has managed to increase toilet coverage and usage especially in rural areas by 96% as stated above. CLTS encourages the use of local resources to build sanitation and hygiene facilities, and its sustainability relies on the availability of these local resources. Since CLTS was being implemented as a project, there is a need to

house can affect the surrounding neighbors and increase the spread of disease. Presence of shrubs, lack of drainage, and poor waste management in households can act as breeding grounds for vectors, resulting in vector-borne diseases such as malaria, affecting a larger part of the community [14, 43]. Households should be properly ventilated to allow fresh air in the house as this would also reduce trans-

ities, and prayer areas (e.g., churches and mosques) [6, 12, 13].

problem in most developing countries [42].

The Relevance of Hygiene to Health in Developing Countries

1.7 Domestic and community hygiene

missions of infections such as flu [44].

same water for drinking and cooking.

14

Poverty is high in developing countries, most households spend less than a dollar a day, and these are classified as extremely poor [47]. This makes them prioritize income so that they buy food, clothes, and other immediate needs placing sanitation and hygiene low in the priority list. Most families struggle to find food, and to them getting food is enough than considering hygiene. Most families start prioritizing hygiene after they move up the development ladder especially when basics like food are no longer a problem [48]. Due to poverty, communities find it difficult to use the only available soap at a household for hand washing [32]. Similarly, hand washing facilities used after visiting a toilet are usually temporary and are made from local materials which are not durable (Figure 2).

#### 2.2 Lack of political commitments

Most of the hygiene initiatives are implemented by nongovernmental organizations (NGOs) and rarely by the government. Despite advocating for water sanitation and hygiene (WASH), there is not enough initiatives introduced by the government through relevant ministries (i.e., Ministry of Health and Ministry of Agriculture, Irrigation and Water Development in Malawi), to enhance hygiene

Figure 2. Hand washing facility at a toilet in rural Malawi.

practices [49]. Hygiene is the major component of provision of safe water and improved sanitation yet it is forgotten during planning of settlements [50]. In general, most countries do not provide enough resources to preventive health, which limits preventive health effectiveness, such as good hygiene practices [51]. For example, in Malawi, the government adopted a Hand Washing with Soap Campaign 2011 to 2012, but after it expired, no new efforts have been made. In addition, the government did not put aside finances to fund hand washing activities. This means hygiene activities will still continue to be implemented by NGOs whenever they have funding. The inconsistencies which the campaign wanted to eliminate will continue to exist [52]. For hygiene to improve, we need governments to plan for implementation and commit resources.

2.5 Lack of information on hygiene infrastructure and practices

Challenges to Hygiene Improvement in Developing Countries

DOI: http://dx.doi.org/10.5772/intechopen.80355

challenge.

2.6 Lack of coordination by hygiene actors

2.7 Lack of clean and adequate water

affects their health [62].

17

2.8 Culture and behavioral issues

Health who also have expertise in implementing them [53].

There is a lack of recent, reliable information on the condition of existing hygiene infrastructure and practices, including whether or not the infrastructure are actually functioning or benefits of some hygiene practices. This makes needs and demands, particularly in remote rural areas frequently unknown, making the task of setting implementation priorities more difficult [53]. However, the rural areas may sometimes have the information but due to the high levels of illiteracy in the developing countries, the community members may not be able to understand the hygiene messages. Making implementation of hygiene is rather difficult. It has also been identified that some people access hygiene information in parts, and they are not fully aware of the hygiene benefits, hence making implementation a

As regard to Malawi, a country in southern Africa, there is a lack of coordination by different sectors involved in hygiene. Different NGOs are after their targets and are not interested in other similar NGOs in the area. In addition, there is institutional fragmentation in developing nations as they lack clarity over whom or which institution(s) is responsible for hygiene. For instance, water, sanitation, and hygiene services are located to ministries of water, thus disregarding Ministry of

Hundreds of millions of people do not have access to clean water in developing nations [15, 60]. The Malawi Demographics and Health Survey, 2016 indicates that on average, 87% of households obtain their water from safe sources. Despite the high reported figure (87%), the situation reveals that most people are not accessible to these improved sources due to their concentration on one geographical location or because the water points often breakdown or sometimes the water from the source is salty especially from boreholes [61]. This makes developing nations to face challenges when it comes to hygiene implementation as most of the hygiene practices require the use of clean water. When water is inadequate and unclean, it results into contamination of hands and foods, thereby spreading infections. Furthermore, insufficient water supply limits good hygiene practices such as bathing and hand washing. Children in developing countries, sometimes clean only some parts of their bodies and not the whole body due to inadequate water and this

Culture shapes the behavior and beliefs of most people as it is the way of people's life. Culture makes people in developing nations to resist to new hygiene facilities and ideas. Additionally, men and women have different perspectives on hygiene due to cultural differences. Different ethnic groups have varying beliefs and customs on hygiene. Lastly, attitudes also vary among people on hygiene in rural and urban areas [7, 50]. Thus, implementation of hygiene faces more challenges due to differences in attitudes, beliefs, and lifestyles of the participants on hygiene projects. One of the hygienic practices that was common is the washing hands by dipping in the same bowl of water by a group of people or family members who eat from the same plate. This practice was common in rural areas of some African

#### 2.3 Lack of community participation during planning phase

As much as there might be a solution, if the people who are receiving the solution do not realize the need for a solution, then the solution becomes ineffective. That is why it is of utmost importance to involve the community during the whole hygiene project. This offers proper understanding of the whole project, and the people further understand the need for the project initiative hence making the projects sustainable. When the people are involved, they get a feeling of ownership of the hygiene project and also understand the benefit of the solution [51]. Additionally, hygiene technologies that are introduced may contradict with some cultural beliefs and this affects adoption and implementation of the hygiene projects in most developing nations. Most hygiene technologies are not user friendly which makes acceptability a challenge [53]. For example, most hand washing facilities have design problems. Some hand washing facilities require users to perform several steps before washing hands and this discourages users from practicing the behavior. The tippy taps are the preferred ones, but they also face problems of durability and use of unpleasant containers and sometimes unsafe water which discourages users just by looking at it [38, 54].

#### 2.4 Lack of gender inclusion

In most cultures, women have the primary responsibility for water, sanitation, and hygiene at the household level [55]. However, most women are left out when it comes to the planning or designing of hygiene projects making the implementation of the project a challenge especially to the women that do not have enough information on the designs [56]. In addition, women sometimes need special consideration when it comes to hygiene infrastructure, for example, a menstrual hygiene management compartment in schools and homes to accommodate women's menstrual hygiene needs [57]. But most times, there is a lack of gender inclusion in the planning and designing [53]. There is less participation in hygiene issues including water supply by men. In African countries, it is the man who is supposed to construct hand washing facilities especially the tippy tap at the toilet and other sanitation facilities including a toilet, but in most of the gatherings related to sanitation and hygiene, its mostly women who participate. Nongovernmental organizations have taken a leading role to encourage women get involved in construction of hygiene facilities including tippy taps [58]. The low participation of men in hygiene intervention limits the translation of messages passed mainly through women into practices due to the lack of physical enabling environment which is supposed to be provided and supported by men as head of households. In addition, men seem to be less inconvenienced by the lack of hygiene at a household [59].

practices [49]. Hygiene is the major component of provision of safe water and improved sanitation yet it is forgotten during planning of settlements [50]. In general, most countries do not provide enough resources to preventive health, which limits preventive health effectiveness, such as good hygiene practices [51]. For example, in Malawi, the government adopted a Hand Washing with Soap Campaign 2011 to 2012, but after it expired, no new efforts have been made. In addition, the government did not put aside finances to fund hand washing activities. This means hygiene activities will still continue to be implemented by NGOs whenever they have funding. The inconsistencies which the campaign wanted to eliminate will continue to exist [52]. For hygiene to improve, we need governments

As much as there might be a solution, if the people who are receiving the solution do not realize the need for a solution, then the solution becomes ineffective. That is why it is of utmost importance to involve the community during the whole hygiene project. This offers proper understanding of the whole project, and the people further understand the need for the project initiative hence making the projects sustainable. When the people are involved, they get a feeling of ownership of the hygiene project and also understand the benefit of the solution [51]. Additionally, hygiene technologies that are introduced may contradict with some cultural beliefs and this affects adoption and implementation of the hygiene projects in most developing nations. Most hygiene technologies are not user friendly which makes acceptability a challenge [53]. For example, most hand washing facilities have design problems. Some hand washing facilities require users to perform several steps before washing hands and this discourages users from practicing the behavior. The tippy taps are the preferred ones, but they also face problems of durability and use of unpleasant containers and sometimes unsafe water which

In most cultures, women have the primary responsibility for water, sanitation, and hygiene at the household level [55]. However, most women are left out when it comes to the planning or designing of hygiene projects making the implementation of the project a challenge especially to the women that do not have enough information on the designs [56]. In addition, women sometimes need special consideration when it comes to hygiene infrastructure, for example, a menstrual hygiene management compartment in schools and homes to accommodate women's menstrual hygiene needs [57]. But most times, there is a lack of gender inclusion in the planning and designing [53]. There is less participation in hygiene issues including water supply by men. In African countries, it is the man who is supposed to construct hand washing facilities especially the tippy tap at the toilet and other sanitation facilities including a toilet, but in most of the gatherings related to sanitation and hygiene, its mostly women who participate. Nongovernmental organizations have taken a leading role to encourage women get involved in construction of hygiene facilities including tippy taps [58]. The low participation of men in hygiene intervention limits the translation of messages passed mainly through women into practices due to the lack of physical enabling environment which is supposed to be provided and supported by men as head of households. In addition, men seem to be less inconvenienced by the lack of hygiene at a household [59].

to plan for implementation and commit resources.

The Relevance of Hygiene to Health in Developing Countries

discourages users just by looking at it [38, 54].

2.4 Lack of gender inclusion

16

2.3 Lack of community participation during planning phase

#### 2.5 Lack of information on hygiene infrastructure and practices

There is a lack of recent, reliable information on the condition of existing hygiene infrastructure and practices, including whether or not the infrastructure are actually functioning or benefits of some hygiene practices. This makes needs and demands, particularly in remote rural areas frequently unknown, making the task of setting implementation priorities more difficult [53]. However, the rural areas may sometimes have the information but due to the high levels of illiteracy in the developing countries, the community members may not be able to understand the hygiene messages. Making implementation of hygiene is rather difficult. It has also been identified that some people access hygiene information in parts, and they are not fully aware of the hygiene benefits, hence making implementation a challenge.

#### 2.6 Lack of coordination by hygiene actors

As regard to Malawi, a country in southern Africa, there is a lack of coordination by different sectors involved in hygiene. Different NGOs are after their targets and are not interested in other similar NGOs in the area. In addition, there is institutional fragmentation in developing nations as they lack clarity over whom or which institution(s) is responsible for hygiene. For instance, water, sanitation, and hygiene services are located to ministries of water, thus disregarding Ministry of Health who also have expertise in implementing them [53].

#### 2.7 Lack of clean and adequate water

Hundreds of millions of people do not have access to clean water in developing nations [15, 60]. The Malawi Demographics and Health Survey, 2016 indicates that on average, 87% of households obtain their water from safe sources. Despite the high reported figure (87%), the situation reveals that most people are not accessible to these improved sources due to their concentration on one geographical location or because the water points often breakdown or sometimes the water from the source is salty especially from boreholes [61]. This makes developing nations to face challenges when it comes to hygiene implementation as most of the hygiene practices require the use of clean water. When water is inadequate and unclean, it results into contamination of hands and foods, thereby spreading infections. Furthermore, insufficient water supply limits good hygiene practices such as bathing and hand washing. Children in developing countries, sometimes clean only some parts of their bodies and not the whole body due to inadequate water and this affects their health [62].

#### 2.8 Culture and behavioral issues

Culture shapes the behavior and beliefs of most people as it is the way of people's life. Culture makes people in developing nations to resist to new hygiene facilities and ideas. Additionally, men and women have different perspectives on hygiene due to cultural differences. Different ethnic groups have varying beliefs and customs on hygiene. Lastly, attitudes also vary among people on hygiene in rural and urban areas [7, 50]. Thus, implementation of hygiene faces more challenges due to differences in attitudes, beliefs, and lifestyles of the participants on hygiene projects. One of the hygienic practices that was common is the washing hands by dipping in the same bowl of water by a group of people or family members who eat from the same plate. This practice was common in rural areas of some African

countries, but is now slowly being replaced with a better practice where each member is poured water when hand washing. The behavior has changed due to serious communicable diseases that were transmitted through washing hands in the same container, for example, cholera [33].

3.3 Provision of menstrual hygiene kits

DOI: http://dx.doi.org/10.5772/intechopen.80355

Challenges to Hygiene Improvement in Developing Countries

women do not have underwear at all [40, 51].

3.4 Making political commitments

commitment is crucial.

19

Despite being a natural process, menstrual hygiene has been considered a taboo in most parts of the world and is rarely talked about, which leads to misinformation. This results in poor menstrual hygiene management among girls and women which further leads to stigma and ill health, absenteeism in schools and increased school drop-out rates. In order for women and girls hygienically manage their menstruation, there is need for a private place to change sanitary cloths and pads, clean water and soap for hand washing, body washing, and washing of reusable clothes [39]. However, most women and girls in developing countries, lack access to clean water for hygiene management. Even worse, they lack proper sanitary cloths to use during menstruation, and they end-up using rags which may result into vaginal infections [67]. For this reason, it is important to introduce menstrual hygiene technologies such as reusable pads so that they may have a safe menstruation, reducing absenteeism in schools and offering them dignity. Furthermore, underwear should be provided to them to make sure that the sanitary pads are used as other girls and

Political commitments especially at high level involving senior government officials are essential toward achieving hygiene improvements. India, Indonesia, and Ethiopia are some of the countries where political commitment by the Prime Minister, Senior Civil Servants, and Ministers, respectively, led to greater achievements in sanitation [68]. Similarly, high level political commitment is required to improve hygiene in developing countries. Most of the times, hygiene

is mentioned during promotion of sanitation, but it should be noted that during implementation, it is often forgotten and hence need to be advocated to separately. National governments should have commitments on hygiene by commissioning a thorough review of policy, making explicit budget allocation on hygiene programs to district and local governments, funding hygiene promotion,

training and capacity building. National governments and NGOs must be in forefront in provision of safe and clean water to be used for hygiene by the users [53]. Political commitment have been found to humper scale up of policies including food and nutrition-related policies and hence need to be given priority

Governments should develop national hygiene strategy and create necessary legislation/regulation to advance the strategy. Additionally, roles and responsibilities of different national institutions to implement the law must be defined properly. Stakeholders must be involved at all the stages of the process to ensure the acceptance of the legislation/regulation by the public. In addition, there must be creation of the mechanisms for monitoring and enforcing implementation of legislation/regulation. This will help those implementing hygiene programs to request specific hygiene regulations to make their programs successful. Lastly, officials that check for compliance of hygiene requirements should be committed to reduce corruption as this will help to ensure quality production and healthy environments

in hygiene improvement [69]. To improve hygiene, high level political

which will prevent the transmission of diseases and infections [70].

3.5 Creating strong legislation and regulations

#### 3. How hygiene can be improved to promote health

#### 3.1 Community empowerment

Households need to be taught on how to make priorities and aim to accomplish them in order of their importance. According to the vicious circle of underdevelopment by Schutte De Wet in 2015, if the very basic needs of a community are met, new and higher ones emerge until the community starts living a better life [63]. Households who are in constant poverty are those who do not use the few resources they find to address their immediate priorities instead they jump and buy things that they do not need in order to conform to society expectation and fulfill their desires. Later, they sell them at cheap price only to come back and buy the priority need. This practice makes them unable to move out of the poverty circle. Once a household is in poverty, it is difficult for them to realize the importance of hygiene and to buy soap or spend resources on hygiene infrastructure. A project in Malawi on healthy settings approach showed that using De Wet tools, it was possible to make community move out of poverty through proper planning using prioritization tools. The project also found out that in communities where people lack basic needs like food and shelter, the issues of sanitation and hygiene are not a priority [48]. In addition, governments need to come up with deliberate pro-poor policies that are aimed at uplifting lives of people in slums and rural areas. Some of the strategies that governments need to employ include targeted subsidies and loans for agriculture and businesses, respectively. In Tanzania, Kagera Region, a project showed that agriculture and trade were the routes for people to move out of poverty [64]. Nepal is one country that has managed to move out of poverty. Absolute poverty decrease by an average rate of 2.2% points between 1995 and 2011 and continued to decline to date. Despite the gains, Nepal needs to come up with policies that will equalize opportunities and level the playing field to enable all people participating in the economy [65].

#### 3.2 Push for equitable access

Different people have different hygiene needs and requirements. As much as millions of people lack access to improved water, sanitation, and hygiene, the situation is worse for people who are physically and socially disabled. They find challenges in using most of the hygiene infrastructure. According to a study conducted in rural and urban Malawi to assess the barriers to accessing water, sanitation and hygiene for disabled people, it was found out that individuals did not report of the same set of barriers. In addition to being physically disabled, factors like being a female, being from a rural setting, and being of limited worth intensify the challenges faced by an individual [66]. It is for this reason that it is essential to understand the needs of different disabled people to ensure equitable access to hygiene, since there is no solution that can solve the challenges of all disabled people. This can be achieved by offering an accommodating hygiene infrastructure and technology for the physically challenged and also at an affordable price to ensure equal access [60].

#### 3.3 Provision of menstrual hygiene kits

countries, but is now slowly being replaced with a better practice where each member is poured water when hand washing. The behavior has changed due to serious communicable diseases that were transmitted through washing hands in the

Households need to be taught on how to make priorities and aim to accomplish them in order of their importance. According to the vicious circle of underdevelopment by Schutte De Wet in 2015, if the very basic needs of a community are met, new and higher ones emerge until the community starts living a better life [63]. Households who are in constant poverty are those who do not use the few resources they find to address their immediate priorities instead they jump and buy things that they do not need in order to conform to society expectation and fulfill their desires. Later, they sell them at cheap price only to come back and buy the priority need. This practice makes them unable to move out of the poverty circle. Once a household is in poverty, it is difficult for them to realize the importance of hygiene and to buy soap or spend resources on hygiene infrastructure. A project in Malawi on healthy settings approach showed that using De Wet tools, it was possible to make community move out of poverty through proper planning using prioritization tools. The project also found out that in communities where people lack basic needs like food and shelter, the issues of sanitation and hygiene are not a priority [48]. In addition, governments need to come up with deliberate pro-poor policies that are aimed at uplifting lives of people in slums and rural areas. Some of the strategies that governments need to employ include targeted subsidies and loans for agriculture and businesses, respectively. In Tanzania, Kagera Region, a project showed that agriculture and trade were the routes for people to move out of poverty [64]. Nepal is one country that has managed to move out of poverty. Absolute poverty decrease by an average rate of 2.2% points between 1995 and 2011 and continued to decline to date. Despite the gains, Nepal needs to come up with policies that will equalize opportunities and level

same container, for example, cholera [33].

The Relevance of Hygiene to Health in Developing Countries

3.1 Community empowerment

3.2 Push for equitable access

ensure equal access [60].

18

3. How hygiene can be improved to promote health

the playing field to enable all people participating in the economy [65].

Different people have different hygiene needs and requirements. As much as millions of people lack access to improved water, sanitation, and hygiene, the situation is worse for people who are physically and socially disabled. They find challenges in using most of the hygiene infrastructure. According to a study conducted in rural and urban Malawi to assess the barriers to accessing water, sanitation and hygiene for disabled people, it was found out that individuals did not report of the same set of barriers. In addition to being physically disabled, factors like being a female, being from a rural setting, and being of limited worth intensify the challenges faced by an individual [66]. It is for this reason that it is essential to understand the needs of different disabled people to ensure equitable access to hygiene, since there is no solution that can solve the challenges of all disabled people. This can be achieved by offering an accommodating hygiene infrastructure and technology for the physically challenged and also at an affordable price to

Despite being a natural process, menstrual hygiene has been considered a taboo in most parts of the world and is rarely talked about, which leads to misinformation. This results in poor menstrual hygiene management among girls and women which further leads to stigma and ill health, absenteeism in schools and increased school drop-out rates. In order for women and girls hygienically manage their menstruation, there is need for a private place to change sanitary cloths and pads, clean water and soap for hand washing, body washing, and washing of reusable clothes [39]. However, most women and girls in developing countries, lack access to clean water for hygiene management. Even worse, they lack proper sanitary cloths to use during menstruation, and they end-up using rags which may result into vaginal infections [67]. For this reason, it is important to introduce menstrual hygiene technologies such as reusable pads so that they may have a safe menstruation, reducing absenteeism in schools and offering them dignity. Furthermore, underwear should be provided to them to make sure that the sanitary pads are used as other girls and women do not have underwear at all [40, 51].

#### 3.4 Making political commitments

Political commitments especially at high level involving senior government officials are essential toward achieving hygiene improvements. India, Indonesia, and Ethiopia are some of the countries where political commitment by the Prime Minister, Senior Civil Servants, and Ministers, respectively, led to greater achievements in sanitation [68]. Similarly, high level political commitment is required to improve hygiene in developing countries. Most of the times, hygiene is mentioned during promotion of sanitation, but it should be noted that during implementation, it is often forgotten and hence need to be advocated to separately. National governments should have commitments on hygiene by commissioning a thorough review of policy, making explicit budget allocation on hygiene programs to district and local governments, funding hygiene promotion, training and capacity building. National governments and NGOs must be in forefront in provision of safe and clean water to be used for hygiene by the users [53]. Political commitment have been found to humper scale up of policies including food and nutrition-related policies and hence need to be given priority in hygiene improvement [69]. To improve hygiene, high level political commitment is crucial.

#### 3.5 Creating strong legislation and regulations

Governments should develop national hygiene strategy and create necessary legislation/regulation to advance the strategy. Additionally, roles and responsibilities of different national institutions to implement the law must be defined properly. Stakeholders must be involved at all the stages of the process to ensure the acceptance of the legislation/regulation by the public. In addition, there must be creation of the mechanisms for monitoring and enforcing implementation of legislation/regulation. This will help those implementing hygiene programs to request specific hygiene regulations to make their programs successful. Lastly, officials that check for compliance of hygiene requirements should be committed to reduce corruption as this will help to ensure quality production and healthy environments which will prevent the transmission of diseases and infections [70].

#### 3.6 Promote gender and equity

Governments and NGOs should frame their policies in the way that include the idea of gender and equity on hygiene promotion. Additionally, they should invest in training or retraining frontline staff to work with men, women, and children [57]. The hygiene framework should be gender sensitive, by enabling women in the development of hygiene policy. They should also ensure that gender provisions address practical and strategic needs for both men and women by taking into consideration of differences in culture and traditions of communities.

implementation of hygiene projects in developing countries, there is a need for promotion of community participation with high youth involvement, strive for equitable access, political commitments, creation of strong legislation, adequate financial resources, and promote gender and equity and make sure that there is the right information flow with the people and that awareness has been raised before

I would like to thank Taonga Mwapasa for her assistance in writing this chapter. I would also like to thank all authors whose work I cited in this document for their

I would like to declare that I do not have conflict of interest.

Department of Environmental Health, University of Malawi, The Polytechnic,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: skumwenda@poly.ac.mw

provided the original work is properly cited.

the implementation of the projects.

Challenges to Hygiene Improvement in Developing Countries

DOI: http://dx.doi.org/10.5772/intechopen.80355

valuable contribution to knowledge.

Acknowledgements

Conflict of interest

Author details

Save Kumwenda

Blantyre, Malawi

21

#### 3.7 Promoting community participation

Community participation is very important as it promotes acceptability and sustainability of hygiene projects [71]. Thus, community members must be involved from initiation phase of the hygiene project to the end phase of the project [72]. This promotes the ownership of projects and communities that are more likely to make use of innovations where they have contributed. Top down approach to projects limits community participation and ownership because the community takes the interventions as external and usually they do not have local input. For example, in Tanzania, a pilot project that used bottom up approach using community structures recorded successful results in terms of reduction of prevalence of schistosomiasis and diarrhea. The project also increased awareness in water, sanitation, and hygiene for disease control [73].

#### 3.8 Involving the youth

Hygiene promotion campaigns are most effective when young population and students involved as beneficiaries and as agents of behavioral change within their families and their communities. Hygiene education that is included in school curricula should be taught conclusively in all schools. Early schools should be the target for hygiene behavior change interventions. Once a child learns about good hygiene at an early age, that child will grow with the behavior and will be able to influence his/her family members and in the long term, the whole community might easily change [71].

#### 4. Conclusion

Hygiene is a broad subject with so many various aspects and is a key aspect in prevention of diseases and promotion of good health. Hygiene has been identified to reduce diarrheal diseases and infections among others, and proper hygiene practices increase dignity, self-esteem, and prestige in the social life. Hygiene can be practiced at personal, domestic, industrial, institutional, and community level, with various sectors playing various roles in enhancement of hygiene as it improves human health. However, for effective hygiene, there is need to incorporate hygiene with sanitation and adequate and clean water supply, since these go hand in hand.

Even though hygiene practices may seem basic, there are a large number of people that lack proper information on hygiene. Such lack of information on hygiene leads to poor hygiene practices that result in disease outbreaks within a society. It is thus important to ensure a proper information flow that helps to communicate to different classes of people in the easiest ways. Effective hygiene communication in schools, markets, industries, and health facilities helps to reach out to a group of people at once and in a specific area. However, for the

Challenges to Hygiene Improvement in Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.80355

implementation of hygiene projects in developing countries, there is a need for promotion of community participation with high youth involvement, strive for equitable access, political commitments, creation of strong legislation, adequate financial resources, and promote gender and equity and make sure that there is the right information flow with the people and that awareness has been raised before the implementation of the projects.

### Acknowledgements

3.6 Promote gender and equity

The Relevance of Hygiene to Health in Developing Countries

3.7 Promoting community participation

tion, and hygiene for disease control [73].

3.8 Involving the youth

change [71].

20

4. Conclusion

Governments and NGOs should frame their policies in the way that include the idea of gender and equity on hygiene promotion. Additionally, they should invest in training or retraining frontline staff to work with men, women, and children [57]. The hygiene framework should be gender sensitive, by enabling women in the development of hygiene policy. They should also ensure that gender provisions address practical and strategic needs for both men and women by taking into

Community participation is very important as it promotes acceptability and sustainability of hygiene projects [71]. Thus, community members must be

involved from initiation phase of the hygiene project to the end phase of the project [72]. This promotes the ownership of projects and communities that are more likely to make use of innovations where they have contributed. Top down approach to projects limits community participation and ownership because the community takes the interventions as external and usually they do not have local input. For example, in Tanzania, a pilot project that used bottom up approach using community structures recorded successful results in terms of reduction of prevalence of schistosomiasis and diarrhea. The project also increased awareness in water, sanita-

Hygiene promotion campaigns are most effective when young population and students involved as beneficiaries and as agents of behavioral change within their families and their communities. Hygiene education that is included in school curricula should be taught conclusively in all schools. Early schools should be the target for hygiene behavior change interventions. Once a child learns about good hygiene at an early age, that child will grow with the behavior and will be able to influence his/her family members and in the long term, the whole community might easily

Hygiene is a broad subject with so many various aspects and is a key aspect in prevention of diseases and promotion of good health. Hygiene has been identified to reduce diarrheal diseases and infections among others, and proper hygiene practices increase dignity, self-esteem, and prestige in the social life. Hygiene can be practiced at personal, domestic, industrial, institutional, and community level, with various sectors playing various roles in enhancement of hygiene as it improves human health. However, for effective hygiene, there is need to incorporate hygiene with sanitation and adequate and clean water supply, since these go hand in hand. Even though hygiene practices may seem basic, there are a large number of people that lack proper information on hygiene. Such lack of information on hygiene leads to poor hygiene practices that result in disease outbreaks within a society. It is thus important to ensure a proper information flow that helps to communicate to different classes of people in the easiest ways. Effective hygiene communication in schools, markets, industries, and health facilities helps to reach

out to a group of people at once and in a specific area. However, for the

consideration of differences in culture and traditions of communities.

I would like to thank Taonga Mwapasa for her assistance in writing this chapter. I would also like to thank all authors whose work I cited in this document for their valuable contribution to knowledge.

### Conflict of interest

I would like to declare that I do not have conflict of interest.

## Author details

Save Kumwenda Department of Environmental Health, University of Malawi, The Polytechnic, Blantyre, Malawi

\*Address all correspondence to: skumwenda@poly.ac.mw

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[18] Mondal D, Minak J, Alam M, Liu Y, Dai J, Korpe P, et al. Contribution of enteric infection, altered intestinal barrier function, and maternal malnutrition to infant malnutrition in Bangladesh. Clinical Infectious Diseases.

[19] Mills JE, Cumming O. The Impact of Water, Sanitation and Hygiene on Key Health and Social Outcomes. Sanitation and Hygiene Applied Research for Equity (SHARE) and UNICEF; p. 112

[20] de Graaf M, Beck R, Caccio SM, Duim B, Fraaij PL, Le Guyader FS, et al. Sustained fecal-oral human-to-human transmission following a zoonotic event. Current Opinion in Virology. 2017;

[21] Freeman MC, Greene LE, Dreibelbis R, Saboori S, Muga R, Brumback B, et al. Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: A cluster-randomized trial. Tropical Medicine & International

Health. 2012;17(3):380-391

[22] Carter RC. Can and should

sanitation and hygiene programmes be expected to achieve health impacts? Waterlines. 2017;36(1):92-103

[23] Curtis V, Cairncross S. Water, sanitation, and hygiene at Kyoto. BMJ.

2003;327(7405):3-4

23

ncbi.nlm.nih.gov/pmc/articles/ PMC4215980/ [cited May 1, 2018]

2012;54(2):185-192

22:1-6

17(9):909-948

[9] Rasool Hassan BA. Importance of Personal Hygiene. Pharmaceutica Analytica Acta. 2012;03(08):1. Available from: https://www.omicsonline. org/importance-of-personal-hygiene-2153-2435.1000e126.php?aid=8931 [cited Ap. 29, 2018]

[10] Oosterom J. The importance of hygiene in modern society. International Biodeterioration and Biodegradation. 1998;41(3):185-189

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Challenges to Hygiene Improvement in Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.80355

Global Burden of Disease Study 2015. The Lancet Infectious Diseases. 2017; 17(9):909-948

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24

Health. 2011;8(1):97-104

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**27**

**Chapter 3**

Nigeria

**Abstract**

Inequalities in Households'

City: The Example of Ile-Ife,

Practices in a Developing Nation's

A new global movement that emerged as a post 2015 development agenda is the sustainable development goals (SDGs). While the central objective of SDGs is to end poverty in all its forms, focus on water and sanitation rested on the fundamental concern for equity; moving from just service delivery to service delivery for all. Hence, the study reported in this chapter was set to examine the state of households' environmental sanitation practices in different residential areas of Ile-Ife, Nigeria. A three-stage multi-sampling procedure was adopted in selecting 283 households' heads for survey. Findings of study showed that 23.6, 41.2, and 68.4% of households in the core, transition, and sub-urban residential areas of Ile-Ife, respectively, have source of water within their residential building. Study established that households' toilet facilities differ significantly in the study area, as respondents socio-economic characteristics varied across the identified residential areas of Ile-Ife. The study thus posited that, if cities in Nigeria and other developing nations will keep tract with timelines of the SDGs on water and sanitation, drastic, and realistic steps must be taken in addressing identified inequalities. This is a way

Environmental Sanitation

*Faniran Gbemiga and Ojo Deborah*

to guaranty adequate hygiene and improved quality of life.

developing nation, inequalities

**1. Introduction**

**Keywords:** households sanitation, environmental sanitation practices, hygiene,

There is a close relationship between man and the environment. It is essential for man to among other things, understands his environment, protects it, conquers, and harnesses it to his ultimate benefit. These are very important as the environment is a complex Web that connects man with the place he lives in; including the natural world as well as things he produces [1]. The environment is a system within which living organism interacts with the physical elements [2, 3]. As the environment constitutes an important factor in the lives of man, its continuous use and misuse have raised globally, concern about possible consequences. These consequences as opined by Taiwo [4] are complex, multi-dimensional, interactive and

#### **Chapter 3**

Maryland, USA: NSO and ICF International; 2016. Available from: http://www.dhsprogram.com/pubs/pdf/ PR73/PR73.pdf [cited Jun 14, 2016]

[cited 2018 May 1]

2015. 56p

46(2):331-349

Ap. 29, 2018]

Hygiene; 2015

26

[62] Hunter PR, AM MD, Carter RC. Water supply and health. PLoS Medicine. 2010;7(11):e1000361. Available from: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC2976720/

The Relevance of Hygiene to Health in Developing Countries

advance food and nutrition security: Piloting a rapid assessment tool. Health Policy and Planning. 2015;30(5):566-578

[70] Nutrition C for FS and A. Hazard Analysis Critical Control Point (HACCP)—HACCP Principles & Application Guidelines [Internet]. 2012. Available from: https://www.fda.gov/ Food/GuidanceRegulation/HACCP/ ucm2006801.htm [cited Jan 11, 2018]

[71] Joshi S. Community participation and ownership of sanitation and hygiene in Western Nepal [thesis]. Diak South, Jar venpaa Unit, Nepal: Diaconia University of Applied Sciences; 2011. Available from: https://www.theseus.fi/ bitstream/handle/10024/35741/Joshi\_ Sudip.pdf [cited Ap. 30, 2018]

[72] Weiss K. One Month in a Floating

[73] Madon S, Malecela MN, Mashoto K, Donohue R, Mubyazi G, Michael E. The role of community participation for sustainable integrated neglected tropical diseases and water, sanitation and hygiene intervention programs: A pilot project in Tanzania. Social Science &

Village. UC Davis College of Engineering, Cambodia; 2016

Medicine. 2018;202:28-37

[63] Wet SD. Identifying Community Needs. Saarbrücken: Scholars Press;

[64] De Weerdt J. Moving out of poverty in Tanzania: Evidence from Kagera. Journal of Development Studies. 2010;

[65] Tiwari S. Moving up the Ladder: Poverty Reduction and Social Mobility in Nepal [Internet]. The World Bank Group. 2016. Available from: http:// documents.worldbank.org/curated/en/

106652-REVISED-WP-Moving-Up-the-Ladder-Executive-Summary.pdf [cited

[66] White S, Kuper H, Itimu-Phiri A, Holm R, Biran A. A qualitative study of barriers to accessing water, sanitation and hygiene for disabled people in Malawi. PLoS One. 2016;11(5):e0155043

[67] Cameroon: Experts Warn of Disease

Outbreaks from Poor Menstrual

[68] WaterAid. Beyond Political Commitment to Sanitation: Navigating Incentives for Prioritisation and Course Correction in Ethiopia, India, and Indonesia [Internet]. WaterAid; 2016. Available from: https://www.google. com/url? [cited Ap. 30, 2018]

[69] Fox AM, Balarajan Y, Cheng C, Reich MR. Measuring political commitment and opportunities to

171641467117954924/pdf/

## Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City: The Example of Ile-Ife, Nigeria

*Faniran Gbemiga and Ojo Deborah*

### **Abstract**

A new global movement that emerged as a post 2015 development agenda is the sustainable development goals (SDGs). While the central objective of SDGs is to end poverty in all its forms, focus on water and sanitation rested on the fundamental concern for equity; moving from just service delivery to service delivery for all. Hence, the study reported in this chapter was set to examine the state of households' environmental sanitation practices in different residential areas of Ile-Ife, Nigeria. A three-stage multi-sampling procedure was adopted in selecting 283 households' heads for survey. Findings of study showed that 23.6, 41.2, and 68.4% of households in the core, transition, and sub-urban residential areas of Ile-Ife, respectively, have source of water within their residential building. Study established that households' toilet facilities differ significantly in the study area, as respondents socio-economic characteristics varied across the identified residential areas of Ile-Ife. The study thus posited that, if cities in Nigeria and other developing nations will keep tract with timelines of the SDGs on water and sanitation, drastic, and realistic steps must be taken in addressing identified inequalities. This is a way to guaranty adequate hygiene and improved quality of life.

**Keywords:** households sanitation, environmental sanitation practices, hygiene, developing nation, inequalities

#### **1. Introduction**

There is a close relationship between man and the environment. It is essential for man to among other things, understands his environment, protects it, conquers, and harnesses it to his ultimate benefit. These are very important as the environment is a complex Web that connects man with the place he lives in; including the natural world as well as things he produces [1]. The environment is a system within which living organism interacts with the physical elements [2, 3]. As the environment constitutes an important factor in the lives of man, its continuous use and misuse have raised globally, concern about possible consequences. These consequences as opined by Taiwo [4] are complex, multi-dimensional, interactive and

cross-sectoral, and hence require inter-organizational collaborations. The coming together of 189 countries of the world in an attempt to face the future, leading to the emergence of the millennium development goals (MDGs), with a target date of 2015 [5] is one of the collaborative efforts to save the environment, and its inhabitants from many mishaps. The significance of the environment to healthy living, national growth, and stability cannot be underestimated. Indeed, almost all indicators of development in the MDGs can be linked to the environment [5].

Among many other fundamental pillars of development entrenched in the MDGs, were water and sanitation, with focus on service delivery. There are several reports on the success and failure rates of MDGs implementation from different countries of the world. Among these are [6–8]. A progress report of the MDGs for Nigeria by United Nations indicated that by 2008, the proportion of households that have access to improved water and sanitation were, respectively, 48 and 53% [9]. More specific and prior to the release of United Nations report [6], it was established that in Lagos State, 36% of households have access to portable water [9]. The report further showed that only 7% of households in the state have access to closet septic tanks. As documented in many MDGs progress reports on water and sanitation in Nigeria, efforts have been devoted to service delivery at the household levels. It is important, however, to examine if there are disparities in the delivery of water and sanitation services, across different residential areas of typical Nigerian city.

To build on many successes of the MDGs, a new global movement that emerged as a post-2015 development agenda is the sustainable development goals (SDGs) [10]. While the central objective of the SDGs is to end poverty in all its forms, focus on water and sanitation rested on the fundamental concern for equity; moving from just service delivery to service delivery for all. Goal six of the SDGs, which is to ensure availability and sustainable management of water and sanitation for all [10, 11], is very central to environmental sanitation and more importantly, developmental activity. The need for an equitable environmental sanitation service delivery cannot be overemphasized. In fact, the attainment of other SDGs, such as Goals 2, 3, 5, 10, and 11 cannot be separated from equitable water and sanitation service delivery. Although the SDG is new, with a target date of 2030, it is imperative to document the level of (in) equalities that exists in environmental sanitation practices at the household and residential neighborhood levels, especially in a developing nation's city. As documented by Osborn, Cutter, Ullah [11], in most developed countries, almost everyone has access to water and sanitation services. There is need to unmask, reduce, and eliminate inequalities in households' sanitation practices in developing nations as well. A way to start these is to first understand the state of environmental sanitation practices in and among different residential areas, social, and income groups.

Environmental sanitation has come to the fore in many developmental discusses, however, with varied definitions. According to [12], environmental sanitation is the sum total of activities embarked upon to protect human bodies from illness, transmission of diseases, or loss of life due to the unclean surrounding. It entails the safe management of human excreta, environmental cleanliness, hand-washing, garbage removal, and wastewater disposal [13, 14]. From these definitions and others [15, 16], environmental sanitation can be construed as comprising, among others; water supply, solid waste management, waste and stormwater management, toilet facilities, and hand-washing. In other words, environmental sanitation entails principles of effecting healthful and hygienic conditions in promoting public health and welfare. Environmental sanitation has input in the various area of health, social balance, urban stability, economic growth and development, and as well as hygiene [17–19]. The social, economic, and environmental health costs of ignoring adequate and effective sanitation (including hygiene) are far too great [20, 21]. Lack of sanitation facilities and poor hygiene are sources of water-borne diseases, such as

**29**

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City…*

diarrhea, cholera, typhoid, and several parasitic infections. The incidence of round worm, whip worm, guinea worm, and schistosomiasis are also linked to poor sanitation. Preventable diseases associated with lack of access to potable water, inadequate sanitation, and poor hygiene have been identified as the source of death of more than 2.2 million people in developing countries [22]. As opined by Daramola, Olowoporoku, and Popoola [23], the consequences of inadequate water supply and

sanitation in cities of sub-Saharan Africa are worse than the claws of a tiger. It is unarguable that environmental sanitation practices differ both in the developed and developing nations of the world. In a study by Faniran, Afon, and Dada [24], it was established that, while there was variation in residents' age, income and education statuses, methods adopted in solid waste storage and disposal by residents across the different residential zones of Ibadan, were not different. Although efforts in [24] was on solid waste management (a fraction of sanitation), it is hypothesized that differences in households' socio-economic characteristics, as well as residential areas, account for disparities in sanitation practices at the household level. In other words, there is a need for an in-depth understanding of existing households' sanitation situation in developing nation's city, with specific attention on water and toilet facilities. The purpose of the study reported in this chapter, is therefore, to examine the state of households' environmental sanitation practices in

The study area, Ile-Ife, is an ancient city in Osun State, Nigeria. It is located approximately between latitude 7°28′ and 7°45' North and Longitude 4°30′ and 4°34′ East of the equator. It is 218 km North East of Lagos. Administratively, the city is made up of two local government areas (LGAs): Ife Central and Ife East. There are, respectively, 11 and 10 political wards in the two identified LGAs [25]. These

Population Commission [26], the population of Ile-Ife was 355,281 by the year 2006. Ile-Ife is widely acknowledged as the cradle of the Yoruba race, whose existence predates Nigeria British colonialism. Yoruba is an ethnic group and the predominant in Southwestern Nigeria. They are also found in other places in the country and

The formation of the different residential settings of many Nigerian cities can be traced to different historical backgrounds [27–29, 24]. These are the pre-colonial (traditional), colonial (non-traditional) and the post-independence (modern) periods. Ile-Ife is not an exemption. Although the classification of [30], indicate the existence of a fourth residential zone in Ile-Ife, termed the post-conflict area, which emerged as a result of communal clashes in the city. Personal observation shows that the once war wreaked area is fast becoming desolate. It is, therefore, important to note that, the inclusion of this fourth zone as the residential area is often adopted in discussing crime-related issues. Residential areas that emerged during each of the earlier mentioned three periods are, respectively, referred to as the core, the transition, and the sub-urban [27–29, 24]. In some other studies [31, 32], the core is regarded as high-density residential area, while the transition and the sub-urban are referred to as the medium and low-density residential areas, respectively. Each of these residential areas is distinctively homogeneous, with respect to physical layout, housing characteristics, environmental qualities, population per square kilometer, and residents' socio-economic statuses. It is, therefore, posited that along with these identified distinctive residential areas, households' sanitation practices will also

area of land. According to National

different residential areas of a typical Nigerian city, Ile-Ife.

**2. Material and methods**

across the globe.

two LGAs cover an approximately 1,791 km2

differ significantly in the study area.

*DOI: http://dx.doi.org/10.5772/intechopen.78304*

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City… DOI: http://dx.doi.org/10.5772/intechopen.78304*

diarrhea, cholera, typhoid, and several parasitic infections. The incidence of round worm, whip worm, guinea worm, and schistosomiasis are also linked to poor sanitation. Preventable diseases associated with lack of access to potable water, inadequate sanitation, and poor hygiene have been identified as the source of death of more than 2.2 million people in developing countries [22]. As opined by Daramola, Olowoporoku, and Popoola [23], the consequences of inadequate water supply and sanitation in cities of sub-Saharan Africa are worse than the claws of a tiger.

It is unarguable that environmental sanitation practices differ both in the developed and developing nations of the world. In a study by Faniran, Afon, and Dada [24], it was established that, while there was variation in residents' age, income and education statuses, methods adopted in solid waste storage and disposal by residents across the different residential zones of Ibadan, were not different. Although efforts in [24] was on solid waste management (a fraction of sanitation), it is hypothesized that differences in households' socio-economic characteristics, as well as residential areas, account for disparities in sanitation practices at the household level. In other words, there is a need for an in-depth understanding of existing households' sanitation situation in developing nation's city, with specific attention on water and toilet facilities. The purpose of the study reported in this chapter, is therefore, to examine the state of households' environmental sanitation practices in different residential areas of a typical Nigerian city, Ile-Ife.

#### **2. Material and methods**

*The Relevance of Hygiene to Health in Developing Countries*

cross-sectoral, and hence require inter-organizational collaborations. The coming together of 189 countries of the world in an attempt to face the future, leading to the emergence of the millennium development goals (MDGs), with a target date of 2015 [5] is one of the collaborative efforts to save the environment, and its inhabitants from many mishaps. The significance of the environment to healthy living, national growth, and stability cannot be underestimated. Indeed, almost all indica-

Among many other fundamental pillars of development entrenched in the MDGs, were water and sanitation, with focus on service delivery. There are several reports on the success and failure rates of MDGs implementation from different countries of the world. Among these are [6–8]. A progress report of the MDGs for Nigeria by United Nations indicated that by 2008, the proportion of households that have access to improved water and sanitation were, respectively, 48 and 53% [9]. More specific and prior to the release of United Nations report [6], it was established that in Lagos State, 36% of households have access to portable water [9]. The report further showed that only 7% of households in the state have access to closet septic tanks. As documented in many MDGs progress reports on water and sanitation in Nigeria, efforts have been devoted to service delivery at the household levels. It is important, however, to examine if there are disparities in the delivery of water and sanitation services, across different residential areas of typical Nigerian city. To build on many successes of the MDGs, a new global movement that emerged as a post-2015 development agenda is the sustainable development goals (SDGs) [10]. While the central objective of the SDGs is to end poverty in all its forms, focus on water and sanitation rested on the fundamental concern for equity; moving from just service delivery to service delivery for all. Goal six of the SDGs, which is to ensure availability and sustainable management of water and sanitation for all [10, 11], is very central to environmental sanitation and more importantly, developmental activity. The need for an equitable environmental sanitation service delivery cannot be overemphasized. In fact, the attainment of other SDGs, such as Goals 2, 3, 5, 10, and 11 cannot be separated from equitable water and sanitation service delivery. Although the SDG is new, with a target date of 2030, it is imperative to document the level of (in) equalities that exists in environmental sanitation practices at the household and residential neighborhood levels, especially in a developing nation's city. As documented by Osborn, Cutter, Ullah [11], in most developed countries, almost everyone has access to water and sanitation services. There is need to unmask, reduce, and eliminate inequalities in households' sanitation practices in developing nations as well. A way to start these is to first understand the state of environmental sanitation practices in and among different residential areas, social, and income groups.

Environmental sanitation has come to the fore in many developmental discusses, however, with varied definitions. According to [12], environmental sanitation is the sum total of activities embarked upon to protect human bodies from illness, transmission of diseases, or loss of life due to the unclean surrounding. It entails the safe management of human excreta, environmental cleanliness, hand-washing, garbage removal, and wastewater disposal [13, 14]. From these definitions and others [15, 16], environmental sanitation can be construed as comprising, among others; water supply, solid waste management, waste and stormwater management, toilet facilities, and hand-washing. In other words, environmental sanitation entails principles of effecting healthful and hygienic conditions in promoting public health and welfare. Environmental sanitation has input in the various area of health, social balance, urban stability, economic growth and development, and as well as hygiene [17–19]. The social, economic, and environmental health costs of ignoring adequate and effective sanitation (including hygiene) are far too great [20, 21]. Lack of sanitation facilities and poor hygiene are sources of water-borne diseases, such as

tors of development in the MDGs can be linked to the environment [5].

**28**

The study area, Ile-Ife, is an ancient city in Osun State, Nigeria. It is located approximately between latitude 7°28′ and 7°45' North and Longitude 4°30′ and 4°34′ East of the equator. It is 218 km North East of Lagos. Administratively, the city is made up of two local government areas (LGAs): Ife Central and Ife East. There are, respectively, 11 and 10 political wards in the two identified LGAs [25]. These two LGAs cover an approximately 1,791 km2 area of land. According to National Population Commission [26], the population of Ile-Ife was 355,281 by the year 2006. Ile-Ife is widely acknowledged as the cradle of the Yoruba race, whose existence predates Nigeria British colonialism. Yoruba is an ethnic group and the predominant in Southwestern Nigeria. They are also found in other places in the country and across the globe.

The formation of the different residential settings of many Nigerian cities can be traced to different historical backgrounds [27–29, 24]. These are the pre-colonial (traditional), colonial (non-traditional) and the post-independence (modern) periods. Ile-Ife is not an exemption. Although the classification of [30], indicate the existence of a fourth residential zone in Ile-Ife, termed the post-conflict area, which emerged as a result of communal clashes in the city. Personal observation shows that the once war wreaked area is fast becoming desolate. It is, therefore, important to note that, the inclusion of this fourth zone as the residential area is often adopted in discussing crime-related issues. Residential areas that emerged during each of the earlier mentioned three periods are, respectively, referred to as the core, the transition, and the sub-urban [27–29, 24]. In some other studies [31, 32], the core is regarded as high-density residential area, while the transition and the sub-urban are referred to as the medium and low-density residential areas, respectively. Each of these residential areas is distinctively homogeneous, with respect to physical layout, housing characteristics, environmental qualities, population per square kilometer, and residents' socio-economic statuses. It is, therefore, posited that along with these identified distinctive residential areas, households' sanitation practices will also differ significantly in the study area.

In order to achieve the purpose of this study, data were collected from selected households in Ile-Ife through questionnaire administration, during the months of November and December, 2017. To select sample for the study, a three-stage multi-sampling procedure was adopted. As earlier mentioned, there were 21 political wards in the two LGAs of the study area: 11 in Ife-Central and 10 in Ife East. Identified political wards were re-grouped into the three different residential areas using stratified sampling technique. Nine of these 21 political wards were located in the core, while there were six in each of the transition and the sub-urban. Simple random sampling technique was used in the second stage in selecting one out of every three political wards in each residential stratum. In other words, seven political wards were selected for the purpose of questionnaire administration. Respondents were drawn from 10% of residential buildings in the selected political wards, using systematic sampling techniques.

In the selected residential building, a questionnaire was administered on a resident who is 18 years old and above. This was adopted, bearing in mind that an individual at this stage in life is no longer a minor; hence could sue or be sued. Similarly, a female respondent was preferred for questionnaire administration in each selected residential building. The allusion to this from the oral commentary is the fact that, among the Yoruba, females were considered as handlers of domestic chores; including household needs of water and sanitation. The practice is that, as soon as a girl child advances in age, she should know how to assist the mother; sweep and clean the house, takes care of the bathroom and toilets, washcloths and cook. The male child is most time spared from all these domestic chores; rather he goes to the farm or another profession with the father. In fact, sanitation was a reserved responsibility of the female folks.

Using the multi-stage sampling technique, 283 respondents were selected for questionnaire administration. Information collected from respondents was their socio-economic characteristics, household's access to water, availability of toilet facility, and methods of solid waste storage and disposal. Information collected from respondents was analyzed using SPSS 17 software. Frequencies of responses were compute, cross-tabbed and expressed in percentages. Responses were also presented in tables and figures. Chi-Square Analysis (χ<sup>2</sup> ) and Analysis of Variance (F) were also used for data analysis at 95% level of confidence (α = 0.005).

#### **3. Findings of study**

Presented in this section are respondents' socio-economic characteristics and sanitation practices. More specifically, issues discussed in sub-section two covered households' access to water supply, toilet facility, solid waste storage, and disposal methods.

#### **3.1 Respondents' socio-economic characteristics**

Socio-economic characteristics of respondents examined in this study were: age, gender, educational qualification, income, and household size. Studies [23, 24, 29, 33, 34] have established the significance of these five characteristics in environmental-related issues; more importantly, when it is about water and sanitation. In other words, these variables will modulate positively or negatively, households' sanitation practices.

The gender distribution of respondents across the three residential areas of Ile-Ife is presented in **Table 1**. Evidence abounds that the proportion of female that

**31**

**Table 1.**

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City…*

participated in the study was more than the male counterpart. It is instructive to note that, this does not suggest that there were more female household heads in the study area than the male household heads. Rather, it is a reflection of the consideration given to the female in the selection of respondents. Of the 283 respondents, 37.1% were male while 62.9% were female. Impliedly, those who were traditionally in the position of handling environmental sanitation and have greater sensitivity toward environmental issue as opined by Zelezny [35] were fully involved in the study. Across the three identified residential areas of Ile-Ife, the female accounted for 63.0, 60.0, and 65.8% of respondents in the core, transition, and sub-urban

no significant difference in gender distribution of respondents across residential

For the purpose of this study, respondents' age was classified into three following the taxonomy of [36]. The groups were: 19–30 years (the youths), 31–55 years (the young adults), and 56–65 (the adults). The grouping was adapted to aid understanding. The study showed that 42.8% of respondents were young adults. On the other hand, the youth and the adult, respectively, accounted for 18.0–39.2% of respondents. As presented in **Table 1**, it is clear that as distance increase from

> **Transition Frequency (%)**

Male 47 (37.0) 32 (40.0) 26 (34.2) 105 (37.1) Female 80 (63.0) 48 (60.0) 50 (65.8) 178 (62.9)

19–30 8 (6.3) 19 (23.7) 21 (27.6) 48 (17.0) 31–55 32 (25.2) 45 (56.3) 47 (61.8) 124 (43.8) 56–70 87 (68.5) 16 (20.0) 8 (10.5) 111 (39.2)

No formal education 55 (43.3) 19 (23.8) 12 (15.8) 86 (30.4) Primary 17 (13.4) 3 (3.7) 3 (4.0) 23 (8.1) Secondary 30 (23.6) 20 (25.0) 9 (11.8) 59 (20.8) Tertiary 25 (19.7) 38 (47.5) 52 (68.4) 115 (40.6)

Below 30000.00 67 (52.8) 38 (47.5) 29 (38.2) 134 (47.3) 30000.00–60000.00 39 (30.7) 25 (31.3) 16 (21.0) 80 (28.3) Above 60000.00 21 (16.5) 17 (21.2) 31 (40.8) 69 (24.4)

1–6 12 (9.4) 39 (48.8) 58 (76.3) 109 (38.5) 6–10 77 (60.6) 37 (46.2) 13 (17.1) 127 (44.9) Above 10 38 (30.0) 4 (5.0) 5 (6.6) 47 (16.6) **N 127 80 76 283**

*\*Naira is Nigeria currency and is denoted by* ₦ *(USD \$1 =* ₦ *360 as at 7th December, 2017).*

*Socio-economic characteristics of respondents in different areas of Ile-Ife.*

= 0.561, *p* = 0.756) confirmed that there was

**Sub-urban Frequency (%)** **Total (%)**

*DOI: http://dx.doi.org/10.5772/intechopen.78304*

areas, respectively. Further analysis (χ<sup>2</sup>

**Core Frequency (%)**

areas of Ile-Ife.

**Residents' Characteristics**

**Gender**

**Age**

**Education status**

**Income status (**₦**\*)**

**Household size**

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City… DOI: http://dx.doi.org/10.5772/intechopen.78304*

participated in the study was more than the male counterpart. It is instructive to note that, this does not suggest that there were more female household heads in the study area than the male household heads. Rather, it is a reflection of the consideration given to the female in the selection of respondents. Of the 283 respondents, 37.1% were male while 62.9% were female. Impliedly, those who were traditionally in the position of handling environmental sanitation and have greater sensitivity toward environmental issue as opined by Zelezny [35] were fully involved in the study. Across the three identified residential areas of Ile-Ife, the female accounted for 63.0, 60.0, and 65.8% of respondents in the core, transition, and sub-urban areas, respectively. Further analysis (χ<sup>2</sup> = 0.561, *p* = 0.756) confirmed that there was no significant difference in gender distribution of respondents across residential areas of Ile-Ife.

For the purpose of this study, respondents' age was classified into three following the taxonomy of [36]. The groups were: 19–30 years (the youths), 31–55 years (the young adults), and 56–65 (the adults). The grouping was adapted to aid understanding. The study showed that 42.8% of respondents were young adults. On the other hand, the youth and the adult, respectively, accounted for 18.0–39.2% of respondents. As presented in **Table 1**, it is clear that as distance increase from


#### **Table 1.**

*Socio-economic characteristics of respondents in different areas of Ile-Ife.*

*The Relevance of Hygiene to Health in Developing Countries*

wards, using systematic sampling techniques.

reserved responsibility of the female folks.

**3. Findings of study**

methods.

practices.

presented in tables and figures. Chi-Square Analysis (χ<sup>2</sup>

**3.1 Respondents' socio-economic characteristics**

In order to achieve the purpose of this study, data were collected from selected households in Ile-Ife through questionnaire administration, during the months of November and December, 2017. To select sample for the study, a three-stage multi-sampling procedure was adopted. As earlier mentioned, there were 21 political wards in the two LGAs of the study area: 11 in Ife-Central and 10 in Ife East. Identified political wards were re-grouped into the three different residential areas using stratified sampling technique. Nine of these 21 political wards were located in the core, while there were six in each of the transition and the sub-urban. Simple random sampling technique was used in the second stage in selecting one out of every three political wards in each residential stratum. In other words, seven political wards were selected for the purpose of questionnaire administration. Respondents were drawn from 10% of residential buildings in the selected political

In the selected residential building, a questionnaire was administered on a resident who is 18 years old and above. This was adopted, bearing in mind that an individual at this stage in life is no longer a minor; hence could sue or be sued. Similarly, a female respondent was preferred for questionnaire administration in each selected residential building. The allusion to this from the oral commentary is the fact that, among the Yoruba, females were considered as handlers of domestic chores; including household needs of water and sanitation. The practice is that, as soon as a girl child advances in age, she should know how to assist the mother; sweep and clean the house, takes care of the bathroom and toilets, washcloths and cook. The male child is most time spared from all these domestic chores; rather he goes to the farm or another profession with the father. In fact, sanitation was a

Using the multi-stage sampling technique, 283 respondents were selected for questionnaire administration. Information collected from respondents was their socio-economic characteristics, household's access to water, availability of toilet facility, and methods of solid waste storage and disposal. Information collected from respondents was analyzed using SPSS 17 software. Frequencies of responses were compute, cross-tabbed and expressed in percentages. Responses were also

Presented in this section are respondents' socio-economic characteristics and sanitation practices. More specifically, issues discussed in sub-section two covered households' access to water supply, toilet facility, solid waste storage, and disposal

Socio-economic characteristics of respondents examined in this study were: age, gender, educational qualification, income, and household size. Studies [23, 24, 29, 33, 34] have established the significance of these five characteristics in environmental-related issues; more importantly, when it is about water and sanitation. In other words, these variables will modulate positively or negatively, households' sanitation

The gender distribution of respondents across the three residential areas of Ile-Ife is presented in **Table 1**. Evidence abounds that the proportion of female that

(F) were also used for data analysis at 95% level of confidence (α = 0.005).

) and Analysis of Variance

**30**

the core toward the sub-urban, the proportion of respondent in the youth and the young adult also increased. Whereas, the proportion of respondent who was adults, reduced as distance increased from the core to the sub-urban. The minimum age was 24 years and the maximum was 62 years. The mean age and standard deviation for the study were 47.8 –9.7 years, respectively. The mean age of residents in the core was 52 years, while that of the transition and sub-urban were 45–42 years, respectively. The standard deviation was 9.7. Differences in the age of respondents across the three residential areas were found to be statistically significant. The result of analysis of variance (F = 36.126 and *p* = 0.000) confirmed this. Impliedly, there is variation in the age of residents in the three identified residential areas of Ibadan metropolis.

A total of 197 (69.6%) of the respondents had one form of formal education or the other. As presented in **Table 2**, 8.1, 20.8, and 40.6% of household heads sampled had primary, secondary and tertiary education qualification, respectively. The highest proportion of respondents with tertiary education qualification was in the sub-urban residential area (68.4%). This group of respondents accounted for 19.7% of residents in the core area, 47.5 and 68.4% of respondents in the transition, and sub-urban areas, respectively. Respondents with no formal education were 86 (30.4%) of sampled household heads in Ile-Ife; however, 64.0, 22.1, and 13.9% of residents in the core, transition, and sub-urban residential areas where in this category. In other words, respondents without formal educational background were predominant in the core area. It can be inferred that there was a direct variation between the educational status of residents and increase in distance from the core toward the suburban. This finding validated the description of [37, 38] that core residential areas of many Nigerian cities are habited by people with the least formal education qualification. Chi-square test computed (₦<sup>2</sup> = 54.477 and *p* = 0.000) also established that there was significant variation in educational status of respondents across residential areas of Ile-Ife.

Respondents' monthly income was grouped into three: low-, medium-, and high-income earners. Respondents who earned below ₦20000.00 were classified as low-income group and accounted for 47.3% of sampled household heads. On the other hand, respondents who earned between ₦20000.00 and ₦60000.00 were the medium income earner, while individuals who earned above ₦60000.00 are the highincome earners. The medium and high-income earners represented 28.3 and 24.4% of respondents, respectively. As presented in **Table 1**, the proportion of respondents in the high-income group increased from the core residential area toward the sub-urban. This pattern was based on the fact that 16.5, 21.2, and 40.8% of the respondents in the core, transition, and sub-urban residential areas, respectively, were high-income earners. Mean income of respondents in the study area was ₦29929.75 and the standard deviation was ₦14372.46. Across the three identified residential areas of Ile-Ife, however, the mean income of respondents differed: while it was ₦18647.32 in the core area, ₦41515.38 in the transition, and it was ₦37784.61 in the sub-urban. Further, One-way analysis of variance test established that there was a significant difference in monthly income of respondents in the study area (F = 141.528, *p* = 0.000).

Household size of respondents was expressed as the number of people or group of people living together under the same roof and eats from the same pot. It is important to add that member of a household share the use of water and another sanitary arrangement. Although in some instances where multi-habitation is prominent, such as the core area [39], sanitary facilities could be shared by more than a household. Respondents household size was thus categorized into small (1–6 people), medium (6–10 people) as well as large (above 10). Households that could be termed small accounted for 9.4% in the core, 48.8% in the transition, and 76.3% in the sub-urban. Evidently, respondents household size varied as residential areas also differed (F = 142.471, *p* = 0.000).

**33**

**Figure 1.**

*Sources of water supply to households within Ile-Ife.*

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City…*

From the above, it is clear that with the exception of respondents' gender distribution, which is not significantly different across the three residential areas of Ile-Ife, other socio-economic characteristics varied as residential areas also varied. This tends to suggest that there will be a disparity in households' access to water and sanitation facilities in the different residential areas of Ile-Ife. The following sub-section is therefore devoted to examining the level of equality that exists in households' access to water and sanitation as well as sanitation practices in the

As shown in **Figure 1**, five sources of water to the households were identified in the study. These were: pipe-borne, well, borehole, rain, and purchase from water vendors. Findings of the study showed that in the core residential area, 44.1% of households have access to pipe-borne water source. Households that sourced water from pipe-borne accounted for 36.3 and 15.8% of households in the transition, and sub-urban areas, respectively. It should be noted here that, the proportion of households that sourced water from the pipe-borne decreased as distance increased from the core to the sub-urban area. The pipe-borne water source is provided as a public service by the government. The study established that while the distance was increasing from the core to the sub-urban, the proportion of household that have access to well water and borehole were also increasing. Rainwater was not a common source in the study area, as only 1.6% of households in the core residential area, representing 0.7% of households in Ile-Ife get water from this source. As earlier stated, this study was conducted in the months of November and December, 2017. These months are regarded as dry/harmattan season in Nigeria. The activity of water vendor was thus prominent in the core area than the other two residential areas. This is despite the fact that households in the core have access to public water supply. This, signals among other things, that households augment the public water

Further inquiry into household access to water showed that sources of water were at different locations. Three major locations were identified (see **Table 2**).

*DOI: http://dx.doi.org/10.5772/intechopen.78304*

**3.2 Households' sanitation practices in Ile-Ife**

supply, which has become epileptic with other sources.

study area.

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City… DOI: http://dx.doi.org/10.5772/intechopen.78304*

From the above, it is clear that with the exception of respondents' gender distribution, which is not significantly different across the three residential areas of Ile-Ife, other socio-economic characteristics varied as residential areas also varied. This tends to suggest that there will be a disparity in households' access to water and sanitation facilities in the different residential areas of Ile-Ife. The following sub-section is therefore devoted to examining the level of equality that exists in households' access to water and sanitation as well as sanitation practices in the study area.

#### **3.2 Households' sanitation practices in Ile-Ife**

*The Relevance of Hygiene to Health in Developing Countries*

tion. Chi-square test computed (₦<sup>2</sup>

also differed (F = 142.471, *p* = 0.000).

areas of Ile-Ife.

the core toward the sub-urban, the proportion of respondent in the youth and the young adult also increased. Whereas, the proportion of respondent who was adults, reduced as distance increased from the core to the sub-urban. The minimum age was 24 years and the maximum was 62 years. The mean age and standard deviation for the study were 47.8 –9.7 years, respectively. The mean age of residents in the core was 52 years, while that of the transition and sub-urban were 45–42 years, respectively. The standard deviation was 9.7. Differences in the age of respondents across the three residential areas were found to be statistically significant. The result of analysis of variance (F = 36.126 and *p* = 0.000) confirmed this. Impliedly, there is variation in the age of residents in the three identified residential areas of Ibadan metropolis. A total of 197 (69.6%) of the respondents had one form of formal education or the other. As presented in **Table 2**, 8.1, 20.8, and 40.6% of household heads sampled had primary, secondary and tertiary education qualification, respectively. The highest proportion of respondents with tertiary education qualification was in the sub-urban residential area (68.4%). This group of respondents accounted for 19.7% of residents in the core area, 47.5 and 68.4% of respondents in the transition, and sub-urban areas, respectively. Respondents with no formal education were 86 (30.4%) of sampled household heads in Ile-Ife; however, 64.0, 22.1, and 13.9% of residents in the core, transition, and sub-urban residential areas where in this category. In other words, respondents without formal educational background were predominant in the core area. It can be inferred that there was a direct variation between the educational status of residents and increase in distance from the core toward the suburban. This finding validated the description of [37, 38] that core residential areas of many Nigerian cities are habited by people with the least formal education qualifica-

there was significant variation in educational status of respondents across residential

Respondents' monthly income was grouped into three: low-, medium-, and high-income earners. Respondents who earned below ₦20000.00 were classified as low-income group and accounted for 47.3% of sampled household heads. On the other hand, respondents who earned between ₦20000.00 and ₦60000.00 were the medium income earner, while individuals who earned above ₦60000.00 are the highincome earners. The medium and high-income earners represented 28.3 and 24.4% of respondents, respectively. As presented in **Table 1**, the proportion of respondents in the high-income group increased from the core residential area toward the sub-urban. This pattern was based on the fact that 16.5, 21.2, and 40.8% of the respondents in the core, transition, and sub-urban residential areas, respectively, were high-income earners. Mean income of respondents in the study area was ₦29929.75 and the standard deviation was ₦14372.46. Across the three identified residential areas of Ile-Ife, however, the mean income of respondents differed: while it was ₦18647.32 in the core area, ₦41515.38 in the transition, and it was ₦37784.61 in the sub-urban. Further, One-way analysis of variance test established that there was a significant difference in

monthly income of respondents in the study area (F = 141.528, *p* = 0.000).

of people living together under the same roof and eats from the same pot. It is important to add that member of a household share the use of water and another sanitary arrangement. Although in some instances where multi-habitation is prominent, such as the core area [39], sanitary facilities could be shared by more than a household. Respondents household size was thus categorized into small (1–6 people), medium (6–10 people) as well as large (above 10). Households that could be termed small accounted for 9.4% in the core, 48.8% in the transition, and 76.3% in the sub-urban. Evidently, respondents household size varied as residential areas

Household size of respondents was expressed as the number of people or group

= 54.477 and *p* = 0.000) also established that

**32**

As shown in **Figure 1**, five sources of water to the households were identified in the study. These were: pipe-borne, well, borehole, rain, and purchase from water vendors. Findings of the study showed that in the core residential area, 44.1% of households have access to pipe-borne water source. Households that sourced water from pipe-borne accounted for 36.3 and 15.8% of households in the transition, and sub-urban areas, respectively. It should be noted here that, the proportion of households that sourced water from the pipe-borne decreased as distance increased from the core to the sub-urban area. The pipe-borne water source is provided as a public service by the government. The study established that while the distance was increasing from the core to the sub-urban, the proportion of household that have access to well water and borehole were also increasing. Rainwater was not a common source in the study area, as only 1.6% of households in the core residential area, representing 0.7% of households in Ile-Ife get water from this source. As earlier stated, this study was conducted in the months of November and December, 2017. These months are regarded as dry/harmattan season in Nigeria. The activity of water vendor was thus prominent in the core area than the other two residential areas. This is despite the fact that households in the core have access to public water supply. This, signals among other things, that households augment the public water supply, which has become epileptic with other sources.

Further inquiry into household access to water showed that sources of water were at different locations. Three major locations were identified (see **Table 2**).

**Figure 1.**

*Sources of water supply to households within Ile-Ife.*



**Table 2.**

*Location of water source in different residential areas of Ile-Ife.*

These were within respondent's residential building, outside the residential building in the neighborhood and outside the neighborhood. Only 115 (40.6%) of households have a water source within their building. Of the 115 households with water source within the building, 52 (45.2%) were in the sub-urban. Households that sourced water from outside their neighborhoods in the study area were 89 (31.5%). Analysis of this figure revealed that 61.8, 29.2, and 9.0% were respectively from the core, transition, and the sub-urban areas. Further investigation revealed that it takes residents a minimum distance range of about 250 m–500 m to travel and source water outside their place of residence. It is thus established that while a considerable proportion of households in the sub-urban area do not travel a longdistance before getting water, result suggests that large proportion of households in the core travel as far as half of a kilometer to source water. It could also be established that households' distances to water source varied with the residential area.

Households' access to toilet facilities was also investigated. In residential areas selected for study, 190 (67.1%) households have toilet facilities. The distribution of responses, however, showed that 51.2% of households in the core, 67.5% in the transition, and 93.4% in the sub-urban residential areas have access to toilet facilities. In other words, the proportion of residents in the study area without access to toilet facilities will employ other methods of defecating such as the use of the open area, near-by bush, and other unfriendly environmental practices. The use of each of these environmentally unfriendly methods has implications for healthy living. These methods are capable of breeding flies and vermin. In areas where the methods are used, an outbreak of diseases and epidemic cannot be negotiated.

In the 190 households where residents have access to toilet facilities, types of toilet used were the flush (62.6%), ventilated improved pit (8.4%), and pit latrine with slab (28.9%). Types of toilet used in the study area also varied with the residential area. The use of flush toilet increased with distance increase from the core to the sub-urban. On the other hand, however, the use of pit latrine was inversely proportional to increase in distance from the core to the sub-urban. Indeed, in the core residential area only, households, where pit latrines were used, accounted for 69.1% of all households that used pit latrine in the study area. In contrast, 88.7% of households that used flush toilet were located in the sub-urban residential area of Ile-Ife. Looking at this information, it could be suggested among other things that a household's choice of type of toilet is influenced by age, educational status, and income of household head, as well as the location of residence in the city.

Across residential areas of Ile-Ife, different methods of solid waste storage and disposal were employed by respondents' households. Among the materials used for storing waste were polythene bag, sack, paper carton, local basket, and bucket with cover as well as without cover. Households also employed different methods for the disposal of waste generated. Dumping inside the drain, along the road,

**35**

**4. Conclusions**

*DOI: http://dx.doi.org/10.5772/intechopen.78304*

**Author details**

Ile-Ife, Nigeria

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City…*

uncompleted building, burying, burning, and the use of designated point in the residential area where the various methods employed in the disposal of solid waste in Ile-Ife. The investigation also revealed that residents dispose waste into skip-eater provided by the government. Although this arrangement is not evident in the suburban area of the city, many of the facilities for disposal provided by the government were concentrated in the core and transition residential areas. The initiative of the paramount ruler of the town is also noticed in solid waste management. Respondent gave an account of the emergence of *gba'fe mo* (Sweep Ife Clean) that was launched by the *Ooni of Ife* in the year 2016. Across the different residential area of the city, there was a disparity in households' accessibility to facilities provided.

This study established among other things that there were significant differences in respondents' socio-economic characteristics across the different residential areas of Ile-Ife. Similarly, there were differences in household's access to water and toilet facilities. These differences have impacted greatly households' sanitation practices. Inequalities in households' income and access to education identified in this study are a potential clogs in the wheel of attaining the SDGs in a typical developing nation's city. There is need, therefore, to develop policies that create an opportunity for all. This is irrespective of who you are, where you reside or come from. There is a need for an improved financial institution, regulation, and market to cater for identified inequalities. Disparities in households' sanitation practices across different residential areas also call for support and development aid where they are most needed, especially among the low-income earners in developing nations. The old direction of households' sanitation must be improved, if developing nations will

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Department of Urban and Regional Planning, Obafemi Awolowo University,

keep track with the post-2015 development agenda.

provided the original work is properly cited.

\*Address all correspondence to: bolafaniran@gmail.com

Faniran Gbemiga\* and Ojo Deborah

*Inequalities in Households' Environmental Sanitation Practices in a Developing Nation's City… DOI: http://dx.doi.org/10.5772/intechopen.78304*

uncompleted building, burying, burning, and the use of designated point in the residential area where the various methods employed in the disposal of solid waste in Ile-Ife. The investigation also revealed that residents dispose waste into skip-eater provided by the government. Although this arrangement is not evident in the suburban area of the city, many of the facilities for disposal provided by the government were concentrated in the core and transition residential areas. The initiative of the paramount ruler of the town is also noticed in solid waste management. Respondent gave an account of the emergence of *gba'fe mo* (Sweep Ife Clean) that was launched by the *Ooni of Ife* in the year 2016. Across the different residential area of the city, there was a disparity in households' accessibility to facilities provided.

#### **4. Conclusions**

*The Relevance of Hygiene to Health in Developing Countries*

*Location of water source in different residential areas of Ile-Ife.*

**Location of water** 

**source**

Outside

**Table 2.**

These were within respondent's residential building, outside the residential building in the neighborhood and outside the neighborhood. Only 115 (40.6%) of households have a water source within their building. Of the 115 households with water source within the building, 52 (45.2%) were in the sub-urban. Households that sourced water from outside their neighborhoods in the study area were 89 (31.5%). Analysis of this figure revealed that 61.8, 29.2, and 9.0% were respectively from the core, transition, and the sub-urban areas. Further investigation revealed that it takes residents a minimum distance range of about 250 m–500 m to travel and source water outside their place of residence. It is thus established that while a considerable proportion of households in the sub-urban area do not travel a longdistance before getting water, result suggests that large proportion of households in the core travel as far as half of a kilometer to source water. It could also be established that households' distances to water source varied with the residential area. Households' access to toilet facilities was also investigated. In residential areas selected for study, 190 (67.1%) households have toilet facilities. The distribution of responses, however, showed that 51.2% of households in the core, 67.5% in the transition, and 93.4% in the sub-urban residential areas have access to toilet facilities. In other words, the proportion of residents in the study area without access to toilet facilities will employ other methods of defecating such as the use of the open area, near-by bush, and other unfriendly environmental practices. The use of each of these environmentally unfriendly methods has implications for healthy living. These methods are capable of breeding flies and vermin. In areas where the meth-

**Core frequency (%) Transition** 

**frequency (%)**

Within building 30 (23.6) 33 (41.2) 52 (68.4) 115 (40.6) In neighborhood 42 (37.0) 21 (26.3) 26 (34.2) 79 (27.9)

Neighborhood 55 (63.0) 26 (32.5) 50 (65.8) 89 (31.5) **Total 127 (100.0) 80 (100.0) 76 (100.0) 283 (100.0)**

**Sub-urban frequency (%)** **Total (%)**

ods are used, an outbreak of diseases and epidemic cannot be negotiated.

income of household head, as well as the location of residence in the city.

Across residential areas of Ile-Ife, different methods of solid waste storage and disposal were employed by respondents' households. Among the materials used for storing waste were polythene bag, sack, paper carton, local basket, and bucket with cover as well as without cover. Households also employed different methods for the disposal of waste generated. Dumping inside the drain, along the road,

In the 190 households where residents have access to toilet facilities, types of toilet used were the flush (62.6%), ventilated improved pit (8.4%), and pit latrine with slab (28.9%). Types of toilet used in the study area also varied with the residential area. The use of flush toilet increased with distance increase from the core to the sub-urban. On the other hand, however, the use of pit latrine was inversely proportional to increase in distance from the core to the sub-urban. Indeed, in the core residential area only, households, where pit latrines were used, accounted for 69.1% of all households that used pit latrine in the study area. In contrast, 88.7% of households that used flush toilet were located in the sub-urban residential area of Ile-Ife. Looking at this information, it could be suggested among other things that a household's choice of type of toilet is influenced by age, educational status, and

**34**

This study established among other things that there were significant differences in respondents' socio-economic characteristics across the different residential areas of Ile-Ife. Similarly, there were differences in household's access to water and toilet facilities. These differences have impacted greatly households' sanitation practices. Inequalities in households' income and access to education identified in this study are a potential clogs in the wheel of attaining the SDGs in a typical developing nation's city. There is need, therefore, to develop policies that create an opportunity for all. This is irrespective of who you are, where you reside or come from. There is a need for an improved financial institution, regulation, and market to cater for identified inequalities. Disparities in households' sanitation practices across different residential areas also call for support and development aid where they are most needed, especially among the low-income earners in developing nations. The old direction of households' sanitation must be improved, if developing nations will keep track with the post-2015 development agenda.

#### **Author details**

Faniran Gbemiga\* and Ojo Deborah Department of Urban and Regional Planning, Obafemi Awolowo University, Ile-Ife, Nigeria

\*Address all correspondence to: bolafaniran@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**36**

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Secretariat; 2009

[7] Mosello B. How to Reduce

[Accessed: January 15, 2018]

Inequalities in Access to WASH—Rural Water and Sanitation in Ghana. Report from Overseas Development Institute, WaterAid. 2017. Available from: https://www.odi.org/sites/odi.org.uk/ files/resourcedocuments/11606.pdf

[8] World Bank. Reducing Inequalities in Water Supply, Sanitation, and

[5] United Nations. Official List of Millennium Development Goal Indicators. 2008. Available from: http:// mdgs.un.org/unsd/mdg/Host.aspx? Content=indicators/officiallist.htm [Accessed: December 18, 2017]

[6] United Nation. World Population Prospects: The 2008 Revision. New York: Population Division of the Department of Economic and Social Affairs of the United Nations

pp. 1-3

[31] Adigun FO, Adedibu AA. Correlates of residents' response to crime in Nigerian cities. Global Journal of Human Social Science. 2013;**13**(5):39- 50. Online ISSN: 2249-460x & Print ISSN: 0975-587X

[32] Wojuade CA. Evaluation of accessibility of socio-economic facilities to residents in Ibadan, Nigeria [thesis]. Ile-Ife, Nigeria: Obafemi Awolowo University; 2012

[33] Akpabio EM. Water meanings, sanitation practices and hygiene behaviours in the cultural mirror: A perspective from Nigeria. Journal of Water, Sanitation and Hygiene for Development. 2012;**2**(3):168-181

[34] Tezera BS. Development impacts of poor accessibility of potable water supply and basic sanitation in rural Ethiopia: A case study of Soddo District water supply and sanitation [thesis]. Agder, Ethopia: University of Agder; 2011

[35] Zelezny LC, Chua PP, Aldrich C. Elaborating on gender differences in environmentalism. Journal of Social Issues. 2000;**56**:443-457

[36] World Health Organisation (WHO). Definition of an Older or Elderly Person. Proposed Working Definition of an Older Person in Africa for the Millennium Development Goal Strategy Project. Geneva, Switzerland: WHO Regional Office; 2011

[37] Eno O. Tenants' willingness to pay for better housing in targeted core area neighbourhoods in Akure Nigeria. Habitat International. 2004;**2**(3):317-332

[38] Lawoyin TO, Lawoyin OOC, Adewole DA. Men's perception of maternal mortality in Nigeria. Journal of Public Health Policy. 2007;**28**:299-318

[39] Okeyinka YR. Multi-habitation in Ogbomoso, Nigeria [thesis]. Ile-Ife, Nigeria: Obafemi Awolowo University; 2016

**39**

**Chapter 4**

Countries

**Abstract**

Community (SADC)

**1. Introduction**

*Ephias M. Makaudze*

Understanding the Hygiene

Needs of People Living with HIV

Developing Community (SADC)

This paper seeks to draw attention to the significance of integrating hygiene practices to HIV and AIDs programs in Southern African Developing Countries (SADC)—a region severely burdened by the disease. Integrating hygiene, in

particular the habit of handwashing with soap and water, can reduce mortality rates and improve the livelihoods of people living with HIV and AIDS (PLWHA)—akin to Florence Nightingale's moment (1850s). The paper uses survey data attained from PLWHA (South Africa) as case point to provide empirical views by PLWHA regarding their views and perceptions about hygiene practices and significance. Key observations are that: PLWHA lack sufficient knowledge on handwashing practices and apparently ignorant about their exposure and extent of vulnerability to opportunistic infections. This paper concludes by making a call for integration of hygiene (especially handwashing with soap and water) as part and parcel of HIV and AIDS programs as this will positively impact livelihoods of PLWHA in SADC. The paper ends continuous monitoring of WASH programs across SADC new 90-90-90 watersanitation-hygiene indicator scoreboard necessary for continuous monitoring of

WASH programs across SADC and equally other developing countries.

**Keywords:** hygiene practices, HIV and AIDS, PLWHA (people living with HIV and AIDS), WASH (water sanitation and hygiene), southern African Development

Is Southern African Development Community (SADC) region winning the 'war' against HIV and AIDs? Maybe not. Most of the SADC countries remain heavily burdened with HIV and AIDS epidemic. Statistics at a glance indicate the region is fighting a losing battle as it continues to endure the highest HIV and AIDs prevalence (11.7%) in the world [15]. An estimated 15.3 million people are infected with the virus including 1.4 million children (**Table 1**). The prevalence is higher in women (53.1%) within the reproductive age group of 15–49 years. New infections, though showing a declining trend, remain high with more than 600,000 people

and AIDs in Southern African

#### **Chapter 4**

*The Relevance of Hygiene to Health in Developing Countries*

[39] Okeyinka YR. Multi-habitation in Ogbomoso, Nigeria [thesis]. Ile-Ife, Nigeria: Obafemi Awolowo University;

2016

[31] Adigun FO, Adedibu AA. Correlates of residents' response to crime in Nigerian cities. Global Journal of Human Social Science. 2013;**13**(5):39- 50. Online ISSN: 2249-460x & Print

accessibility of socio-economic facilities to residents in Ibadan, Nigeria [thesis]. Ile-Ife, Nigeria: Obafemi Awolowo

[32] Wojuade CA. Evaluation of

[33] Akpabio EM. Water meanings, sanitation practices and hygiene behaviours in the cultural mirror: A perspective from Nigeria. Journal of Water, Sanitation and Hygiene for Development. 2012;**2**(3):168-181

[34] Tezera BS. Development impacts of poor accessibility of potable water supply and basic sanitation in rural Ethiopia: A case study of Soddo District water supply and sanitation [thesis]. Agder, Ethopia: University of Agder;

[35] Zelezny LC, Chua PP, Aldrich C. Elaborating on gender differences in environmentalism. Journal of Social

Definition of an Older or Elderly Person. Proposed Working Definition of an Older Person in Africa for the Millennium Development Goal Strategy Project. Geneva, Switzerland: WHO

[37] Eno O. Tenants' willingness to pay for better housing in targeted core area neighbourhoods in Akure Nigeria. Habitat International.

[38] Lawoyin TO, Lawoyin OOC, Adewole DA. Men's perception of maternal mortality in Nigeria. Journal of Public Health Policy. 2007;**28**:299-318

[36] World Health Organisation (WHO).

Issues. 2000;**56**:443-457

Regional Office; 2011

2004;**2**(3):317-332

ISSN: 0975-587X

University; 2012

2011

**38**

Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African Developing Community (SADC) Countries

*Ephias M. Makaudze*

### **Abstract**

This paper seeks to draw attention to the significance of integrating hygiene practices to HIV and AIDs programs in Southern African Developing Countries (SADC)—a region severely burdened by the disease. Integrating hygiene, in particular the habit of handwashing with soap and water, can reduce mortality rates and improve the livelihoods of people living with HIV and AIDS (PLWHA)—akin to Florence Nightingale's moment (1850s). The paper uses survey data attained from PLWHA (South Africa) as case point to provide empirical views by PLWHA regarding their views and perceptions about hygiene practices and significance. Key observations are that: PLWHA lack sufficient knowledge on handwashing practices and apparently ignorant about their exposure and extent of vulnerability to opportunistic infections. This paper concludes by making a call for integration of hygiene (especially handwashing with soap and water) as part and parcel of HIV and AIDS programs as this will positively impact livelihoods of PLWHA in SADC. The paper ends continuous monitoring of WASH programs across SADC new 90-90-90 watersanitation-hygiene indicator scoreboard necessary for continuous monitoring of WASH programs across SADC and equally other developing countries.

**Keywords:** hygiene practices, HIV and AIDS, PLWHA (people living with HIV and AIDS), WASH (water sanitation and hygiene), southern African Development Community (SADC)

#### **1. Introduction**

Is Southern African Development Community (SADC) region winning the 'war' against HIV and AIDs? Maybe not. Most of the SADC countries remain heavily burdened with HIV and AIDS epidemic. Statistics at a glance indicate the region is fighting a losing battle as it continues to endure the highest HIV and AIDs prevalence (11.7%) in the world [15]. An estimated 15.3 million people are infected with the virus including 1.4 million children (**Table 1**). The prevalence is higher in women (53.1%) within the reproductive age group of 15–49 years. New infections, though showing a declining trend, remain high with more than 600,000 people


#### **Table 1.**

*SADC HIV and AIDs statistics at a glance 2016.*

infected with HIV virus and more than 500,000 people having died due to HIV in 2016. About 7.6 million children have been orphaned by disease and this in turn feeds into other socio-economic problems such as, the observed increase in the number of street kids, drug abuse, prostitution, gangs and gun violence, etc. In addition access to antiretroviral treatment (ART) remains limited in the region with only 48.2% receiving treatment.

A number of factors can be attributed to the high prevalence of HIV and AIDS in SADC region and key among them include: acute poverty especially in urban slums and associated problems of high crime rate, rampant prostitution, sexual violence, sexually transmitted diseases and infections; high mobility and influx of migrants particularly from neighbouring countries to South Africa; social depravation and high inequality within the region; limited and uneven access to quality medical care.

UN-Habitat [13] predicts that by 2020 a majority of people (>60%) in Africa would be living in major cities in search for employment and better life. The trend is equally observed in SADC countries, where most of the major cities are currently experiencing a boom in urban population. Correlated with increasing urban population is the proliferation of urban slum settlements and the resultant intensification of poverty as most of the new urbanites are not formally employed. Slum settlements generally consists of haphazardly scattered and overcrowded dwelling units characterised by lack of reliable supply of clean water, safe sanitation, hygienic living, reliable electricity, law enforcement and other basic services.

A number of studies indicate that the highest proportion of PLWHA reside in slum settlements [10, 12] (AIDS Foundation 2010). For instance **Table 2** indicates the settlement pattern of PLWHA in South Africa. As observed, a majority of PLWHA within 15–49 years age group predominantly dwell in poor urban slum settlements (25.8%), followed by rural slums (17.3%). In general, these settlement patterns have direct implications on WASH (water, sanitation and hygiene) provision.

This remainder of this paper is structured as follows: Section 2 provides an overview of WASH in SADC including links between HIV/AIDS and WASH; Section 3 discusses how hygiene matters for PLWHA; Section 4 showcases anecdotal evidence


**41**

**Table 3.**

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African…*

based on empirical views, knowledge, perceptions and understanding of hygiene

Hygiene practice has long been recognised as a critical component of public health programs associated with WASH. Yet despite its critical importance, hygiene has not received much priority in WASH policy programs. Under MDG (2000– 2015) water and sanitation received global focus including high research priority with well-defined targets. However, under the new SDGs, significance of hygiene is recognised and explicitly included as part and parcel of WASH. Specifically, SDG target 6.2 represents the increasing recognition and role of hygiene and its close links with sanitation. Hygiene is multifaceted as it can comprise many aspects (e.g. handwashing, menstrual hygiene and food hygiene, etc.) and this makes it difficult

WASH practitioners have until recently identified handwashing with soap and water as a top priority in all hygiene settings, and a suitable indicator for national and global monitoring [18]. This new global SDG indicator for handwashing is defined as the '*proportion of population with handwashing facilities with soap and water at home*'. Handwashing facilities consist an array of devices such as, sink with tap water, buckets with taps, tippy-taps and portable basins, etc. Bar soap, liquid soap, powder detergent and soapy water all count as soap for monitoring purposes. In other cases, ashes, soil, sand and other materials are often used as handwashing soap substitutes, but these are less effective than soap and therefore counted as

The WHO/UNICEF's Joint Monitoring Program (JMP) has stepped up efforts to develop 'handwashing with soap and water' as primary indicator for global monitoring of hygiene under the SDGs. As a result JMP has recently developed a new 'ladder' intended to benchmark and compare progress in hygiene provision across countries. The new hygiene ladder is shown in **Table 3** illustrating three hygiene service levels: first, the *basic level* which is fulfilled when the household has a handwashing facility with soap and water available on premises; second, *limited level* which is met when the household has facility on premises but lacks water and soap; and third, *no facility* occurs when the household has no any form of handwashing

Using this approach, JMP (under WHO/UNICEF [18]) conducted baseline survey to assess hygiene provision worldwide. The results indicate that the least developing countries (SADC region included), 27% of the population had access to 'handwashing facilities with soap and water' on premises, while 26% had handwashing facilities but lacking soap or water, and the rest (47%) had no facility.

Basic level Availability of handwashing facility on premises with soap and water; soap devices include

Availability of handwashing facility on premises without soap and water; non-soap devices

*DOI: http://dx.doi.org/10.5772/intechopen.80356*

**2. Overview of WASH in SADC**

limited handwashing facilities.

available on his/her premises.

**Level defined**

No facility No handwashing on premises

bar soap, powder detergents, soapy water

like ashes, sand are used instead

**Services level**

Limited level

*Source: WHO/UNICEF [18].*

*The new JMP ladder for hygiene.*

needs by PLWHA in South Africa and Section 5 concludes.

to integrate measure and/or monitor performance WaterAID [16].

**Table 2.**

*Distribution of PLWHA in urban and rural settlements in South Africa.*

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African… DOI: http://dx.doi.org/10.5772/intechopen.80356*

based on empirical views, knowledge, perceptions and understanding of hygiene needs by PLWHA in South Africa and Section 5 concludes.

#### **2. Overview of WASH in SADC**

*The Relevance of Hygiene to Health in Developing Countries*

only 48.2% receiving treatment.

*SADC HIV and AIDs statistics at a glance 2016.*

*Source: UNAIDS [15].*

**Table 1.**

infected with HIV virus and more than 500,000 people having died due to HIV in 2016. About 7.6 million children have been orphaned by disease and this in turn feeds into other socio-economic problems such as, the observed increase in the number of street kids, drug abuse, prostitution, gangs and gun violence, etc. In addition access to antiretroviral treatment (ART) remains limited in the region with

People living with HIV 15.3 million Adults HIV prevalence 12.9% Women HIV prevalence 53.1% New HIV infections 620,000 AIDs-related deaths 530,000 Adults on antiretroviral treatment 8.6 million

living, reliable electricity, law enforcement and other basic services.

direct implications on WASH (water, sanitation and hygiene) provision.

A number of studies indicate that the highest proportion of PLWHA reside in slum settlements [10, 12] (AIDS Foundation 2010). For instance **Table 2** indicates the settlement pattern of PLWHA in South Africa. As observed, a majority of PLWHA within 15–49 years age group predominantly dwell in poor urban slum settlements (25.8%), followed by rural slums (17.3%). In general, these settlement patterns have

This remainder of this paper is structured as follows: Section 2 provides an overview of WASH in SADC including links between HIV/AIDS and WASH; Section 3 discusses how hygiene matters for PLWHA; Section 4 showcases anecdotal evidence

**Type of settlement HIV+ (whole sample) HIV prevalence (15–49)**

Urban formal 9.1% 13.9% Urban slum 17.6% 25.8% Rural formal 9.9% 13.9% Rural slum 11.6% 17.3%

*Distribution of PLWHA in urban and rural settlements in South Africa.*

A number of factors can be attributed to the high prevalence of HIV and AIDS in SADC region and key among them include: acute poverty especially in urban slums and associated problems of high crime rate, rampant prostitution, sexual violence, sexually transmitted diseases and infections; high mobility and influx of migrants particularly from neighbouring countries to South Africa; social depravation and high inequality within the region; limited and uneven access to quality medical care. UN-Habitat [13] predicts that by 2020 a majority of people (>60%) in Africa would be living in major cities in search for employment and better life. The trend is equally observed in SADC countries, where most of the major cities are currently experiencing a boom in urban population. Correlated with increasing urban population is the proliferation of urban slum settlements and the resultant intensification of poverty as most of the new urbanites are not formally employed. Slum settlements generally consists of haphazardly scattered and overcrowded dwelling units characterised by lack of reliable supply of clean water, safe sanitation, hygienic

**40**

**Table 2.**

*Source: Tomlison [12].*

Hygiene practice has long been recognised as a critical component of public health programs associated with WASH. Yet despite its critical importance, hygiene has not received much priority in WASH policy programs. Under MDG (2000– 2015) water and sanitation received global focus including high research priority with well-defined targets. However, under the new SDGs, significance of hygiene is recognised and explicitly included as part and parcel of WASH. Specifically, SDG target 6.2 represents the increasing recognition and role of hygiene and its close links with sanitation. Hygiene is multifaceted as it can comprise many aspects (e.g. handwashing, menstrual hygiene and food hygiene, etc.) and this makes it difficult to integrate measure and/or monitor performance WaterAID [16].

WASH practitioners have until recently identified handwashing with soap and water as a top priority in all hygiene settings, and a suitable indicator for national and global monitoring [18]. This new global SDG indicator for handwashing is defined as the '*proportion of population with handwashing facilities with soap and water at home*'. Handwashing facilities consist an array of devices such as, sink with tap water, buckets with taps, tippy-taps and portable basins, etc. Bar soap, liquid soap, powder detergent and soapy water all count as soap for monitoring purposes. In other cases, ashes, soil, sand and other materials are often used as handwashing soap substitutes, but these are less effective than soap and therefore counted as limited handwashing facilities.

The WHO/UNICEF's Joint Monitoring Program (JMP) has stepped up efforts to develop 'handwashing with soap and water' as primary indicator for global monitoring of hygiene under the SDGs. As a result JMP has recently developed a new 'ladder' intended to benchmark and compare progress in hygiene provision across countries. The new hygiene ladder is shown in **Table 3** illustrating three hygiene service levels: first, the *basic level* which is fulfilled when the household has a handwashing facility with soap and water available on premises; second, *limited level* which is met when the household has facility on premises but lacks water and soap; and third, *no facility* occurs when the household has no any form of handwashing available on his/her premises.

Using this approach, JMP (under WHO/UNICEF [18]) conducted baseline survey to assess hygiene provision worldwide. The results indicate that the least developing countries (SADC region included), 27% of the population had access to 'handwashing facilities with soap and water' on premises, while 26% had handwashing facilities but lacking soap or water, and the rest (47%) had no facility.


#### **Table 3.**

*The new JMP ladder for hygiene.*

The graphic results are shown in **Figure 1**, showing the proportion of people with handwashing facilities including soap and water at home across different countries. It's striking to observe that across all SADC countries less than 50% of population have handwashing facilities with soap and water at their premises. The result imply dire implications especially for PLWHA. It is reasonable to infer that because of limited access to safe sanitation (see **Table 4**), many PLWHA are succumbing to communicable diseases predominantly due to lack of hygienic living.

#### **2.1 HIV/AIDS link with WASH**

Where is the link between HIV/AIDS and WASH issues? HIV and AIDS is not a waterborne disease nor is it spread via poor hygiene-related diseases like diarrhoea, typhoid and cholera [6, 7]. On one hand HIV and AIDS is principally a sexually transmitted disease, while on the other hand, water is a renewable resource whose availability depends on a variety of natural geographic and climatic factors. Likewise, sanitation and hygiene practices appear completely unrelated to HIV. Ostensibly, on face value, HIV and WASH issues appear distantly unrelated.

To the contrary, there are important links between HIV/AIDs and water/sanitation/hygiene with strong bearing on efficient provision and delivery of WASH services by municipalities [1].

First, AIDS kills by destroying the immune system of the body—rendering the body highly susceptible to common diseases. As a result AIDS victims die after succumbing to one or more of "opportunistic diseases" especially waterborne diseases such as diarrhoea, cholera, dysentery, typhoid, etc. For example, diarrhoea rates are estimated to be 2–6 times higher in PLWHA than in non-infected and rates of acute and persistent diarrhoea are twice as high in PLWHA compared to the noninfected ([5] in [17]).

Second, as PLWHA become frail, bed-ridden and increasingly incapacitated their demand for WASH (Makaudze & Gelles, 2015) services drastically increases [9]. For instance, they would require regular bathing, frequent washing of soiled linen and clothes, clean hygiene living environment with well-managed solid waste disposal. Safe sanitation involves proper handling and disposal of human excreta (faeces, urine, menstrual blood, and sweat), proper management of wastes (including trash, wastewater, sewage and hazardous wastes) and proper control of disease vectors such as mosquitoes and flies [14, 17]. However providing such essential WASH services for PLWHA in slum and rural settlements is a formidable challenge.

#### **Figure 1.**

*Proportion of national population with handwashing facilities including soap and water at home, 2015. Source: WHO/UNICEF [15].*

**43**

SADC region.

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African…*

**Country Access to clean water (%) Access to safe sanitation (%) % hygiene** Angola 48 52 – Botswana 95 65 – Lesotho 82 30 – Malawi 90 41 – Madagascar 52 12 – Mauritius 100 94 – Mozambique 51 20 – Namibia 90 35 – South Africa 92 68 – Swaziland 75 58 – Tanzania 56 15 – Zambia 66 44 – Zimbabwe 78 38 – Average 78 44 –

Third, hygiene practice that predominantly involves handwashing with soap and

water is not a common practice among PLWHA. If the practice is routinely conducted at critical times, handwashing can effectively reduce diarrhoea instances. Some studies conducted in developing countries concluded that handwashing

Menstruation management for women living with HIV and AIDs is another important aspect that requires shrewd hygiene standards. Menstrual blood of HIV positive women contains the virus and can be hazardous risk to family members,

Despite the potential benefits of WASH practices, meeting the special needs of PLWHA remains an enormous challenge in many SADC countries. While significant progress has been achieved in water and sanitation provision, it is hygiene component of WASH that has not received much policy attention and priority (see **Table 4**). Hygiene practice cuts across water and sanitation sectors and its efficient provision will benefit everyone, and incorporating hygiene into HIV programmes will provide additional opportunities to improve overall public health outcomes in

The paper seeks to draw attention to the essence of integrating hygiene practices to HIV and AIDs programs in SADC and other developing countries equally burdened by the disease. Integrating hygiene practices could have a profound impact

A small but growing body of literature is emerging recognising the need to integrate hygiene practices in HIV and AIDs programmes in SADC and equally other developing countries. To gain better understanding of hygiene practices, the following questions are interrogated: first, what is hygiene and how can it be integrated as

practices with soap can lower the risk of diarrhoea by 42–44% [2, 3].

caregivers and other people if not properly handled and managed.

on reducing mortality and improving the livelihoods of PLWHA.

**3. Hygiene is critical for PLWHA**

*DOI: http://dx.doi.org/10.5772/intechopen.80356*

*Source: UNAIDS Data Compilation [15].*

*WASH provision across SADC countries.*

**Table 4.**


*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African… DOI: http://dx.doi.org/10.5772/intechopen.80356*

#### **Table 4.**

*The Relevance of Hygiene to Health in Developing Countries*

**2.1 HIV/AIDS link with WASH**

services by municipalities [1].

infected ([5] in [17]).

The graphic results are shown in **Figure 1**, showing the proportion of people with handwashing facilities including soap and water at home across different countries. It's striking to observe that across all SADC countries less than 50% of population have handwashing facilities with soap and water at their premises. The result imply dire implications especially for PLWHA. It is reasonable to infer that because of limited access to safe sanitation (see **Table 4**), many PLWHA are succumbing to

Where is the link between HIV/AIDS and WASH issues? HIV and AIDS is not a waterborne disease nor is it spread via poor hygiene-related diseases like diarrhoea, typhoid and cholera [6, 7]. On one hand HIV and AIDS is principally a sexually transmitted disease, while on the other hand, water is a renewable resource whose availability depends on a variety of natural geographic and climatic factors. Likewise, sanitation and hygiene practices appear completely unrelated to HIV. Ostensibly, on face value, HIV and WASH issues appear distantly unrelated. To the contrary, there are important links between HIV/AIDs and water/sanitation/hygiene with strong bearing on efficient provision and delivery of WASH

First, AIDS kills by destroying the immune system of the body—rendering the body highly susceptible to common diseases. As a result AIDS victims die after succumbing to one or more of "opportunistic diseases" especially waterborne diseases such as diarrhoea, cholera, dysentery, typhoid, etc. For example, diarrhoea rates are estimated to be 2–6 times higher in PLWHA than in non-infected and rates of acute and persistent diarrhoea are twice as high in PLWHA compared to the non-

Second, as PLWHA become frail, bed-ridden and increasingly incapacitated their demand for WASH (Makaudze & Gelles, 2015) services drastically increases [9]. For instance, they would require regular bathing, frequent washing of soiled linen and clothes, clean hygiene living environment with well-managed solid waste disposal. Safe sanitation involves proper handling and disposal of human excreta (faeces, urine, menstrual blood, and sweat), proper management of wastes (including trash, wastewater, sewage and hazardous wastes) and proper control of disease vectors such as mosquitoes and flies [14, 17]. However providing such essential WASH services for PLWHA in slum and rural settlements is a formidable challenge.

*Proportion of national population with handwashing facilities including soap and water at home, 2015. Source:* 

communicable diseases predominantly due to lack of hygienic living.

**42**

**Figure 1.**

*WHO/UNICEF [15].*

*WASH provision across SADC countries.*

Third, hygiene practice that predominantly involves handwashing with soap and water is not a common practice among PLWHA. If the practice is routinely conducted at critical times, handwashing can effectively reduce diarrhoea instances. Some studies conducted in developing countries concluded that handwashing practices with soap can lower the risk of diarrhoea by 42–44% [2, 3].

Menstruation management for women living with HIV and AIDs is another important aspect that requires shrewd hygiene standards. Menstrual blood of HIV positive women contains the virus and can be hazardous risk to family members, caregivers and other people if not properly handled and managed.

Despite the potential benefits of WASH practices, meeting the special needs of PLWHA remains an enormous challenge in many SADC countries. While significant progress has been achieved in water and sanitation provision, it is hygiene component of WASH that has not received much policy attention and priority (see **Table 4**). Hygiene practice cuts across water and sanitation sectors and its efficient provision will benefit everyone, and incorporating hygiene into HIV programmes will provide additional opportunities to improve overall public health outcomes in SADC region.

The paper seeks to draw attention to the essence of integrating hygiene practices to HIV and AIDs programs in SADC and other developing countries equally burdened by the disease. Integrating hygiene practices could have a profound impact on reducing mortality and improving the livelihoods of PLWHA.

#### **3. Hygiene is critical for PLWHA**

A small but growing body of literature is emerging recognising the need to integrate hygiene practices in HIV and AIDs programmes in SADC and equally other developing countries. To gain better understanding of hygiene practices, the following questions are interrogated: first, what is hygiene and how can it be integrated as part of WASH programs? Second, which hygiene practices are critical to PLWHAs? Third, what are perceptions and understanding of hygiene practices by PLWHA?

Hygiene can be defined as a set of deliberate actions undertaken to preserve health, prevent sickness and enhance individual or community's safety and health security. Simply defined, it is the "deliberate act and habit of preserving health security". The actions may be instituted and/or enforced by the government in the interest of preserving individual or public health security. The World Health Organisation [17] defines hygiene practices as conditions that "help maintain health and prevent the spread of diseases". Personal characteristics, socio-economic and cultural factors play a role in the adoption of hygiene practices.

The term hygiene originated from the ancient Greek and basically means "that which is healthy". Its name is coined from the Greek "god of health" called Hygeia. Today the term is widely applied particularly in WASH where its meaning has been expanded to include issues such as; personal hygiene, water hygiene, sanitation hygiene, food hygiene, public hygiene, environmental hygiene, etc.

Florence Nightingale (1820–1910), regarded as the godmother of hygiene, was the "first" to apply hygiene practices to the wounded combatants during the Crimean War (1853–1856). Nightingale's approach included providing proper ventilation, heating, light, clean environment, clean beds and bedding, personal hygiene, food and nutrition hygiene. What underlies the significance of Nightingale's approach was to facilitate and provide a conducive environment that resulted in lowering mortality rates by two-thirds. Her work provoked such profound effect that sparked worldwide healthcare reforms. It is the Nightingale's moment that we seek to apply by facilitating and promoting hygiene practices with the potential to reduce mortality rates of PLWHA. Because a majority of PLWHA dwell in rural and urban slum settlements (as discussed earlier) where they face deplorable living conditions marked by serious lack of safe sanitation, improvement in hygiene practices is critical for the sustenance of livelihoods of PLWHA.

#### **3.1 Essential hygiene practices for PLWHA**

This section provides a brief overview of the essential hygiene practices critical for PLWHA in SADC. The main hygiene components that need to be integrated in HIV and AIDS programs include (but not limited to) water hygiene, sanitation hygiene and personal hygiene and these are discussed below (see [17] for detailed discussion).

#### *3.1.1 Water hygiene*

Quality water is unavailable in many slum and rural settlements across SADC countries. In some cases water may be available but often untreated or contaminated—posing a high risk to PLWHA. Several affordable technologies are available for treating water and these include water chlorination, filtration, proper boiling, solar disinfection and ultraviolet radiation [17]. Such low-cost strategies for water treatment at the household level can greatly improve the microbial quality of water and can reduce diarrhoeal instance by 30–40%, achieving outcomes [11, 14, 17].

Ideal water hygiene can be regarded as water that has been subjected to such treatment as boiling, chlorination, filtration, solar disinfection including safe storage facilities. Water boiling is perhaps the most commonly popular and convenient approach especially for rural households where there is a general lack of electricity. Besides water boiling, chlorination is another widely practised water treatment especially at community level. Chlorinated water can be safe for drinking up to 7 days. A variety of different chemical substances can be used for water chlorination,

**45**

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African…*

e.g. sodium hypochlorite, (a bleaching powder), calcium hypochlorite or sodium

NaDCC tablets are increasingly being used for routine drinking water treatment in especially in urban areas. The tablets provide cheap alternative chlorine source for use in the safe water system. In comparison to the chlorine solution, the tablets have benefits such as low cost, long shelf life, resistance to sunlight degradation,

Solar disinfection (SODIS) is another water hygiene practise gaining popularity in developing countries. SODIS uses UV-A radiation from the sun for treating water. Because solar energy is easily available across SADC countries, SODIS can be used as a cheaply available water treatment approach. Unlike chlorination methods (discussed above), SODIS does not affect the colour, taste, or odour of the water. However the approach has distinct disadvantages; can only be used when the water is clear (and not turbid water); requires small transparent plastic bottles (e.g. 1–2 l); requires long periods for effective treatment (6 hours in bright sun or 2 days in cloudy weather) and treating large quantities of water is problematic as this would require

Ideal hygiene sanitation for PLWHA can be defined as a facility with infrastructure which is safe, reliable, private, protected from the weather, well-ventilated, minimum smells, easily accessible, access clean, minimises the risk of spreading sanitation-related diseases. In particular, hygiene sanitation requires proper handling and disposal of human excreta (faeces, urine, menstrual blood, and sweat), proper management of wastes (including trash, wastewater, sewage and hazardous

HIV/AIDS policy programs in many SADC countries have not prioritised the provision of hygienic sanitation particularly in slum settlements that are essentially convenient for PLWHA. For instance, a significant proportion (>20%) of households in slum settlements in South Africa still use the condemned bucket system or

The results presented below are intended to showcase the views and understanding of hygiene practices by PLWHA in South Africa. The results are drawn from a research grant conducted by the author as one of the principal researchers and supported by Water Research Commission (WRC, 2009–2011). The study was based on 485 HIV and AIDs individuals drawn from three different types of settlements (rural, peri-urban and urban slums) and sampled from three selected municipal districts of Khayelitsha (Western Cape Province), Ukhahlamba (Eastern Cape Province) and Groblersdal (Limpopo Province). The district of Khayelitsha typically represents urban slum type of settlements, while on the other hand, the districts of Ukhahlamba and Grobersdal represent rural and peri-urban type of settlements respectively. The results are reproduced in this paper (courtesy of WRC) to provide empirical anecdotal evidence on hygiene practices and interpretation in the lens of PLWHA in South Africa. In other words, the results seek to demonstrate perceptions by PLWHA regarding: their understanding of hygiene practices, views on effectiveness of hygiene campaigns by local municipalities and

wastes) and proper control of disease vectors such as flies and pests.

**4. Empirical views on hygiene by PLWA: case of South Africa**

how hygiene improvement is likely to impact their livelihoods.

bushes and open space for defecation [4, 8].

*DOI: http://dx.doi.org/10.5772/intechopen.80356*

single-use package easy to distribute due to low weight [17].

dichloroisocyanurate (NaDCC) [17].

large plastic containers.

*3.1.2 Sanitation hygiene*

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African… DOI: http://dx.doi.org/10.5772/intechopen.80356*

e.g. sodium hypochlorite, (a bleaching powder), calcium hypochlorite or sodium dichloroisocyanurate (NaDCC) [17].

NaDCC tablets are increasingly being used for routine drinking water treatment in especially in urban areas. The tablets provide cheap alternative chlorine source for use in the safe water system. In comparison to the chlorine solution, the tablets have benefits such as low cost, long shelf life, resistance to sunlight degradation, single-use package easy to distribute due to low weight [17].

Solar disinfection (SODIS) is another water hygiene practise gaining popularity in developing countries. SODIS uses UV-A radiation from the sun for treating water. Because solar energy is easily available across SADC countries, SODIS can be used as a cheaply available water treatment approach. Unlike chlorination methods (discussed above), SODIS does not affect the colour, taste, or odour of the water. However the approach has distinct disadvantages; can only be used when the water is clear (and not turbid water); requires small transparent plastic bottles (e.g. 1–2 l); requires long periods for effective treatment (6 hours in bright sun or 2 days in cloudy weather) and treating large quantities of water is problematic as this would require large plastic containers.

#### *3.1.2 Sanitation hygiene*

*The Relevance of Hygiene to Health in Developing Countries*

cultural factors play a role in the adoption of hygiene practices.

hygiene, food hygiene, public hygiene, environmental hygiene, etc.

is critical for the sustenance of livelihoods of PLWHA.

**3.1 Essential hygiene practices for PLWHA**

*3.1.1 Water hygiene*

part of WASH programs? Second, which hygiene practices are critical to PLWHAs? Third, what are perceptions and understanding of hygiene practices by PLWHA? Hygiene can be defined as a set of deliberate actions undertaken to preserve health, prevent sickness and enhance individual or community's safety and health security. Simply defined, it is the "deliberate act and habit of preserving health security". The actions may be instituted and/or enforced by the government in the interest of preserving individual or public health security. The World Health Organisation [17] defines hygiene practices as conditions that "help maintain health and prevent the spread of diseases". Personal characteristics, socio-economic and

The term hygiene originated from the ancient Greek and basically means "that which is healthy". Its name is coined from the Greek "god of health" called Hygeia. Today the term is widely applied particularly in WASH where its meaning has been expanded to include issues such as; personal hygiene, water hygiene, sanitation

Florence Nightingale (1820–1910), regarded as the godmother of hygiene, was the "first" to apply hygiene practices to the wounded combatants during the Crimean War (1853–1856). Nightingale's approach included providing proper ventilation, heating, light, clean environment, clean beds and bedding, personal hygiene,

This section provides a brief overview of the essential hygiene practices critical for PLWHA in SADC. The main hygiene components that need to be integrated in HIV and AIDS programs include (but not limited to) water hygiene, sanitation hygiene and personal hygiene and these are discussed below (see [17] for detailed discussion).

Quality water is unavailable in many slum and rural settlements across SADC countries. In some cases water may be available but often untreated or contaminated—posing a high risk to PLWHA. Several affordable technologies are available for treating water and these include water chlorination, filtration, proper boiling, solar disinfection and ultraviolet radiation [17]. Such low-cost strategies for water treatment at the household level can greatly improve the microbial quality of water and can reduce diarrhoeal instance by 30–40%, achieving outcomes [11, 14, 17]. Ideal water hygiene can be regarded as water that has been subjected to such treatment as boiling, chlorination, filtration, solar disinfection including safe storage facilities. Water boiling is perhaps the most commonly popular and convenient approach especially for rural households where there is a general lack of electricity. Besides water boiling, chlorination is another widely practised water treatment especially at community level. Chlorinated water can be safe for drinking up to 7 days. A variety of different chemical substances can be used for water chlorination,

food and nutrition hygiene. What underlies the significance of Nightingale's approach was to facilitate and provide a conducive environment that resulted in lowering mortality rates by two-thirds. Her work provoked such profound effect that sparked worldwide healthcare reforms. It is the Nightingale's moment that we seek to apply by facilitating and promoting hygiene practices with the potential to reduce mortality rates of PLWHA. Because a majority of PLWHA dwell in rural and urban slum settlements (as discussed earlier) where they face deplorable living conditions marked by serious lack of safe sanitation, improvement in hygiene practices

**44**

Ideal hygiene sanitation for PLWHA can be defined as a facility with infrastructure which is safe, reliable, private, protected from the weather, well-ventilated, minimum smells, easily accessible, access clean, minimises the risk of spreading sanitation-related diseases. In particular, hygiene sanitation requires proper handling and disposal of human excreta (faeces, urine, menstrual blood, and sweat), proper management of wastes (including trash, wastewater, sewage and hazardous wastes) and proper control of disease vectors such as flies and pests.

HIV/AIDS policy programs in many SADC countries have not prioritised the provision of hygienic sanitation particularly in slum settlements that are essentially convenient for PLWHA. For instance, a significant proportion (>20%) of households in slum settlements in South Africa still use the condemned bucket system or bushes and open space for defecation [4, 8].

#### **4. Empirical views on hygiene by PLWA: case of South Africa**

The results presented below are intended to showcase the views and understanding of hygiene practices by PLWHA in South Africa. The results are drawn from a research grant conducted by the author as one of the principal researchers and supported by Water Research Commission (WRC, 2009–2011). The study was based on 485 HIV and AIDs individuals drawn from three different types of settlements (rural, peri-urban and urban slums) and sampled from three selected municipal districts of Khayelitsha (Western Cape Province), Ukhahlamba (Eastern Cape Province) and Groblersdal (Limpopo Province). The district of Khayelitsha typically represents urban slum type of settlements, while on the other hand, the districts of Ukhahlamba and Grobersdal represent rural and peri-urban type of settlements respectively. The results are reproduced in this paper (courtesy of WRC) to provide empirical anecdotal evidence on hygiene practices and interpretation in the lens of PLWHA in South Africa. In other words, the results seek to demonstrate perceptions by PLWHA regarding: their understanding of hygiene practices, views on effectiveness of hygiene campaigns by local municipalities and how hygiene improvement is likely to impact their livelihoods.

#### *The Relevance of Hygiene to Health in Developing Countries*


#### **Table 5.**

*Understanding hygienic practices by PLWHA in South Africa.*

The results in **Table 5** indicate "hygiene practices" undertaken by PLWHA across the three sampled areas. Results show most interviewees indicating '*wash your body regularly'* (34%) as the most dominant hygiene practice, followed by '*wash hands before eating*' (32.2%). A rather surprising result is the practice of 'w*ash hands after toilet use*', with less than 10% indicating this practice. The smallest proportion was in Groblersdal and the highest in Khayelitsha. Some differences exist between the three areas with those in Khayelitsha being much more focused on washing regularly (than in the other two areas) and having a much lower percentage regarding *washing hands before eating* as important. The result suggest serious lack of knowledge by PLWHA of crucial hygiene practices of handwashing during critical times.

In recent years, local municipalities have mounted several campaigns aimed at improving provision of general public health and security. **Table 6** shows that more than half of the all interviewees were aware of any such campaigns. Khayelitsha had the least awareness (31.3%) and Groblersdal the highest (>90%). Overall, for those individuals who indicated awareness of such campaigns, there was the general perception the campaigns were not effective.


**47**

practices.

important insights:

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African…*

Type of settlement Urban slum Rural Peri-urban Will improve health status 31.1% 38.4% 22.9% 42.0% Will reduce opportunistic infection 9.4% 9.6% 9.1% 18.8%

Likely to live longer 24.4% 15.2% 34.9% 8.9% Enhances my dignity 16.1% 17.7% 15.4% 10.7% Other 2.4% 3.0% 1.7% 0.0%

**All Khayelitsha Ukhahlamba Groblersdal**

12.5% 9.5% 16.0% 17.9%

Overall, more than 80% of interviewees thought the campaigns should target PLWHA. Of these, the overwhelming view was that such campaigns should target

The results in **Table 7** indicate perceptions by PLWHA on the potential impact of improved provision of hygiene practices. The interviewees' dominant view was that improvement in hygiene practices will improve their health status— Nightingale's moment. Results also indicate that interviewees think they are likely to live longer (24.4%) with improvements in hygiene practices and in addition this could also enhance dignity (16.1%). A low proportion (<10%) of interviewees expressed the view that improved hygiene practices could reduce opportunistic infection or reduce vulnerability to water-borne diseases (12.5%). This result imply the lack of knowledge by PLWHA on how vulnerable they are to unhygienic

The empirical results discussed above help to highlight some important implications regarding perceptions on hygiene practices by PLWHA in general. Although hard and fast statements may not be drawn, the results nonetheless underlie

• The results point to serious lack of sufficient knowledge on how "handwashing" as a hygiene practice, can have such a profound effect on the health status of PLWHA. Handwashing is one of the interventions that promote hygiene, since it can stop the transmission of pathogens that cause various diseases (e.g. diarrhoea, cholera, etc.). If done properly and at critical times, handwashing with soap and water (basic level) or even abrasive material such as ashes (limited level) is effective in preventing the spread of communicable diseases (e.g. diarrhoea, cholera). Studies conducted in developing countries have concluded that handwashing can

*DOI: http://dx.doi.org/10.5772/intechopen.80356*

Will reduce vulnerability to water-

*Source: Water Research Commission [8].*

borne diseases

**Table 7.**

educating people on water and sanitation.

*Perceptions by PLWHA on likely impact of improved hygiene practices.*

**5. Implications of empirical results**

a. *lack of sufficient knowledge on handwashing practices*

significantly reduce the mortality of PLWHA.

b. *health campaigns on HIV/AIDS must integrate WASH*

#### **Table 6.**

*Awareness of hygiene campaigns and perceptions on effectiveness by PLWHA.*

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African… DOI: http://dx.doi.org/10.5772/intechopen.80356*


#### **Table 7.**

*The Relevance of Hygiene to Health in Developing Countries*

*Source: Water Research Commission [8].*

**Table 5.**

hygiene practices of handwashing during critical times.

*Understanding hygienic practices by PLWHA in South Africa.*

perception the campaigns were not effective.

Should they target people living with

*Source: Water Research Commission [8].*

*Awareness of hygiene campaigns and perceptions on effectiveness by PLWHA.*

HIV/AIDS? (Yes)

The results in **Table 5** indicate "hygiene practices" undertaken by PLWHA across the three sampled areas. Results show most interviewees indicating '*wash your body regularly'* (34%) as the most dominant hygiene practice, followed by '*wash hands before eating*' (32.2%). A rather surprising result is the practice of 'w*ash hands after toilet use*', with less than 10% indicating this practice. The smallest proportion was in Groblersdal and the highest in Khayelitsha. Some differences exist between the three areas with those in Khayelitsha being much more focused on washing regularly (than in the other two areas) and having a much lower percentage regarding *washing hands before eating* as important. The result suggest serious lack of knowledge by PLWHA of crucial

Type of settlement Urban slum Rural Peri-urban N= 485 198 175 112 Wash hands before eating 32.2% 42.9% 38.9% 2.7% Wash hands after toilet use 7.0% 12.8% 4.6% 1.0% Wash hands with soap 3.7% 8.1% 1.1% 0.0% Wash your body regularly 34.0% 29.3% 24.0% 58.1% Clean toilet with detergents 1.4% 2.5% 1.1% 0.0% Other 9.7% 2.5% 0.6% 36.6%

In recent years, local municipalities have mounted several campaigns aimed at improving provision of general public health and security. **Table 6** shows that more than half of the all interviewees were aware of any such campaigns. Khayelitsha had the least awareness (31.3%) and Groblersdal the highest (>90%). Overall, for those individuals who indicated awareness of such campaigns, there was the general

Type of settlement Urban slum Rural Peri-urban N= 485 198 175 112 Aware of campaigns? (Yes) 54.4% 31.3% 57.1% 91.1% Very effective 19.2% 3.5% 22.3% 42.0% Effective 25.4% 12.6% 27.4% 44.6% Not effective 5.1% 7.1% 0.6% 3.6%

How to keep body clean 1.9% 1.5% 3.4% 0.0% Education on water & sanitation 47.8% 46.4% 56.0% 37.5% How to avoid opportunistic infection 1.0% 1.5% 1.1% 0.0% Other 18.8% 3.0% 11.4% 58.0%

**All Khayelitsha Ukhahlamba Groblersdal**

**All Khayelitsha Ukhahlamba Groblersdal**

87.4% 88.4% 81.1% 95.5%

**46**

**Table 6.**

*Perceptions by PLWHA on likely impact of improved hygiene practices.*

Overall, more than 80% of interviewees thought the campaigns should target PLWHA. Of these, the overwhelming view was that such campaigns should target educating people on water and sanitation.

The results in **Table 7** indicate perceptions by PLWHA on the potential impact of improved provision of hygiene practices. The interviewees' dominant view was that improvement in hygiene practices will improve their health status— Nightingale's moment. Results also indicate that interviewees think they are likely to live longer (24.4%) with improvements in hygiene practices and in addition this could also enhance dignity (16.1%). A low proportion (<10%) of interviewees expressed the view that improved hygiene practices could reduce opportunistic infection or reduce vulnerability to water-borne diseases (12.5%). This result imply the lack of knowledge by PLWHA on how vulnerable they are to unhygienic practices.

#### **5. Implications of empirical results**

The empirical results discussed above help to highlight some important implications regarding perceptions on hygiene practices by PLWHA in general. Although hard and fast statements may not be drawn, the results nonetheless underlie important insights:

#### a. *lack of sufficient knowledge on handwashing practices*

	- PLWHA seem to be ignorant about how vulnerable they are to opportunistic infections especially waterborne and skin diseases because of compromised immuno-system. Diarrhoea in particular is the number one killer. This result emphasises the need to raise awareness and educational campaigns among PLWHA about vulnerability to opportunistic infections and significant role hygiene practices especially the role handwashing with soap and water can play in reducing morbidity and mortality rates.

#### d. *improvement in hygiene practices will provide "Nightingale's moment" to PLWHA*

• Perhaps the most important result by PLWHA is that improvement in hygiene practices will improve health status. This calls upon all stakeholders in health and WASH sectors across SADC countries to integrate hygiene practices particularly handwashing as part and parcel of national HIV and AIDS policy programs. The desired outcome is that such approach will provide 'Nightingale's moment' to PLWHA.

#### e. *implement new 90-90-90 water-sanitation-hygiene indicator scoreboard*

• The 90-90-90 is an ambitious treatment program initiated by UNAIDS working to end the AIDS epidemic by 2020. The program stipulates that by 2020, 90% of all PLWHA will know their HIV status; by 2020, 90% of all PLWHA will receive sustained antiretroviral therapy and by 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. Following a similar approach, it could be prudent to launch 90-90-90 water-sanitation-hygiene indicator scoreboard by 2020. This could interpreted as by 2020, across all SADC countries (and/or developing countries) 90% of population must have access to clean water; 90% of population must use safe sanitation and 90% of population must have handwashing facilities with soap and water on the premises. With many SADC countries lagging behind in sanitation provision, special emphasis can be devoted to promote 'handwashing with water and soap' campaigns targeting PLWHA.

#### **6. Conclusion**

There is overwhelming evidence that improvement in hygiene practices will reduce opportunistic infection especially water borne diseases. Hygiene practices particularly handwashing with soap and water have the potential to reduce

**49**

**Author details**

Illinois, USA

Ephias M. Makaudze

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Visiting Professor, Business and Economics Department, Wheaton College,

\*Address all correspondence to: ephias.makaudze@wheaton.edu

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African…*

morbidity and mortality rates among PLWHA. However despite the potential benefits of hygiene practices, full implementation and meeting the special needs of PLWHA remains an enormous challenge in SADC. While significant progress has been achieved in water and sanitation provision it is hygiene component of WASH that has not received much policy attention and/or priority. This paper has made a case calling for the integration of hygiene practices (particularly handwashing with soap and water) in HIV and AIDS programs as this will provide additional opportunities to improve health outcomes and reduce mortality of PLWHA akin to

With reference to survey data used in this paper, the author acknowledges, with gratitude, the valuable contribution by Drs Natasha Poitigier (University of Venda) and Materlla du Preez (Centre for Scientific and Industrial Research, Pretoria), who both participated as part of the research team and principal researchers. The author is grateful for the support provided by Water Research Commission (Pretoria, South Africa) under grant project number K5/1813/3. The views expressed in this paper belong to the author and do not represent or reflect the position or policies of

*DOI: http://dx.doi.org/10.5772/intechopen.80356*

Nightangle's moment across SADC countries.

**Acknowledgements**

Water Research Commission.

*Understanding the Hygiene Needs of People Living with HIV and AIDs in Southern African… DOI: http://dx.doi.org/10.5772/intechopen.80356*

morbidity and mortality rates among PLWHA. However despite the potential benefits of hygiene practices, full implementation and meeting the special needs of PLWHA remains an enormous challenge in SADC. While significant progress has been achieved in water and sanitation provision it is hygiene component of WASH that has not received much policy attention and/or priority. This paper has made a case calling for the integration of hygiene practices (particularly handwashing with soap and water) in HIV and AIDS programs as this will provide additional opportunities to improve health outcomes and reduce mortality of PLWHA akin to Nightangle's moment across SADC countries.

#### **Acknowledgements**

*The Relevance of Hygiene to Health in Developing Countries*

• The approach by most governments in SADC has been to treat HIV and AIDS as a purely health issue and completely divorced from non-health yet complementary sectors (e.g. WASH). Most HIV and AIDS campaign programs rolled out by governments are predominantly focussed on preventive efforts and measures particularly aimed at changing sexual behaviour; e.g. the ABC (**a**bstain-**b**e-faithful-**c**ondom) campaigns. Such approaches have downplayed the complementary role other essential non-health sectors can play in reducing the impact of HIV and AIDS. The government Departments of Health and Water and Sanitation need to work hand-inhand in coordinating or developing joint national programs that integrate WASH as part and parcel of HIV and AIDS programs targeting PLWHA.

c. *lack of knowledge on extent of vulnerability to opportunistic infections by PLWHA*

• PLWHA seem to be ignorant about how vulnerable they are to opportunistic infections especially waterborne and skin diseases because of compromised immuno-system. Diarrhoea in particular is the number one killer. This result emphasises the need to raise awareness and educational campaigns among PLWHA about vulnerability to opportunistic infections and significant role hygiene practices especially the role handwashing with

soap and water can play in reducing morbidity and mortality rates.

d. *improvement in hygiene practices will provide "Nightingale's moment" to PLWHA*

• Perhaps the most important result by PLWHA is that improvement in hygiene practices will improve health status. This calls upon all stakeholders in health and WASH sectors across SADC countries to integrate hygiene practices particularly handwashing as part and parcel of national HIV and AIDS policy programs. The desired outcome is that such approach will

• The 90-90-90 is an ambitious treatment program initiated by UNAIDS working to end the AIDS epidemic by 2020. The program stipulates that by 2020, 90% of all PLWHA will know their HIV status; by 2020, 90% of all PLWHA will receive sustained antiretroviral therapy and by 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. Following a similar approach, it could be prudent to launch 90-90-90 water-sanitation-hygiene indicator scoreboard by 2020. This could interpreted as by 2020, across all SADC countries (and/or developing countries) 90% of population must have access to clean water; 90% of population must use safe sanitation and 90% of population must have handwashing facilities with soap and water on the premises. With many SADC countries lagging behind in sanitation provision, special emphasis can be devoted to promote 'handwashing with water and soap' campaigns targeting PLWHA.

There is overwhelming evidence that improvement in hygiene practices will reduce opportunistic infection especially water borne diseases. Hygiene practices particularly handwashing with soap and water have the potential to reduce

provide 'Nightingale's moment' to PLWHA.

e. *implement new 90-90-90 water-sanitation-hygiene indicator scoreboard*

**48**

**6. Conclusion**

With reference to survey data used in this paper, the author acknowledges, with gratitude, the valuable contribution by Drs Natasha Poitigier (University of Venda) and Materlla du Preez (Centre for Scientific and Industrial Research, Pretoria), who both participated as part of the research team and principal researchers. The author is grateful for the support provided by Water Research Commission (Pretoria, South Africa) under grant project number K5/1813/3. The views expressed in this paper belong to the author and do not represent or reflect the position or policies of Water Research Commission.

#### **Author details**

Ephias M. Makaudze Visiting Professor, Business and Economics Department, Wheaton College, Illinois, USA

\*Address all correspondence to: ephias.makaudze@wheaton.edu

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**53**

Section 3

Water Handling

Challenges Affecting

Hygiene and Health

## Section 3
