What causes sustainable changes in hygiene behaviour? A cross-sectional study from Kerala, India.

This study was designed and the field work carried out by a non-governmental organisation (NGO) responsible for implementing hygiene promotion. The sustainability of changed hygiene behaviour was studied at various periods up to nine years after the conclusion of a multifaceted hygiene promotion intervention in Kerala, India. Various methods including a questionnaire to assess knowledge, spot observation, demonstration of skills on request, and household pocket voting were used and compared for the measurement of the hygiene outcome. Pocket voting gave the lowest prevalence of good practice, which we infer to be the more accurate. Good handwashing practice was reported by more than half the adults in intervention areas, but < 10% in a control area. Handwashing prevalence showed no association with the elapsed time since the interventions, indicating that behaviour change had occurred and persisted. Recall of participation in health education classes was significantly associated with good hygiene as indicated by women's handwashing practice (OR 2.04, CI 1.05-3.96) and by several other outcomes, suggesting that the classes were an effective component of the intervention. The evidence for a specific impact on behaviour from home visits and an awareness campaign is less strong, although the home visits had influenced knowledge. The finding of an association between interventions and male handwashing, in ecological analysis (comparing administrative areas i.e. panchayats) but not at individual level, suggests that the effect of the interventions on men may have been indirect, via women or neighbours, underlining the need to direct interventions at men as well as women. The finding that hygiene behaviour persisted for years implies that hygiene promotion is a more cost-effective health intervention than previously supposed.