Hygiene refers to the practices that help to maintain health and prevent the spread of diseases. While good hygiene is primarily about behaviours, the ability to practise them well is supported by having the appropriate infrastructure in place, such as access to clean water and soap.

Poor water, sanitation and hygiene (WASH) increases death rates and ill health, creates greater demand for healthcare interventions, widens social inequalities, and has repercussions for quality of life and the wider economy.

There are two main transmission routes for infection—the faecal-oral and respiratory pathways—and hygiene measures work by disrupting them.

Attaining good hygiene is complex, and it is becoming increasingly clear that a more holistic approach is needed that engages and empowers local populations, and is locally sensitive and sustainable.

The life-course approach, which has its origins in preventing or reducing the impact of non-communicable diseases through encouraging good behaviours while recognising the contribution of other factors, including environmental ones, could provide a useful framework for communicable disease and hygiene. Looking at hygiene through a life-course lens could form part of a smarter approach that embeds good hygiene behaviour from childhood (to gain the most cumulative benefit), and then reinforces it throughout a person’s lifetime to boost good hygiene practices if these start to wane.

This report looks at the burden, challenges and opportunities of a life-course approach at four key life stages by focusing on specific infectious diseases or challenges at those time points.

Childhood and hygiene: a focus on diarrhoea

Every year diarrhoeal diseases kill around 0.5m children under five, with the majority of deaths in South Asia and sub-Saharan Africa.   The majority of diarrhoeal deaths in low- and middle-income countries (LMICs) across all age groups can be attributed to WASH. Handwashing with soap can reduce transmission of diarrhoeal diseases and, to a lesser extent, respiratory infections. It is estimated that handwashing with soap after faecal contact only occurs in about 26% of events globally,, and the frequency of handwashing was lowest in regions with poor access to handwashing facilities. In 2017 the UN estimated that 3bn people lacked basic handwashing facilities at home. Furthermore almost half (47%) of schools worldwide lack handwashing facilities with available soap and water,  and one in four health care facilities lack basic water services. 

Experience from implementing hygiene interventions in schools and health centres suggests that interventions to improve hygiene in LMICs need to be two pronged, encouraging handwashing behaviour while also improving infrastructure to enable it.

Adolescence and hygiene: a focus on menstrual hygiene

Around 1.9bn women—about 26% of the world’s population—are of menstruating age, spending around 65 days per annum managing menstrual blood flow. As defined by the WHO/UNICEF Joint Monitoring Programme for Water Supply Sanitation and Hygiene (JMP), adequate menstrual hygiene requires women and adolescent girls to be able to access clean menstrual management material to absorb or collect menstrual blood, change their sanitary protection in privacy, have access to soap and water to clean themselves and wash reusable pads, and have an understanding of the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear.

Although menstrual hygiene issues impact girls and women across the globe, they have the biggest impact in LMICs where cultural, social and religious beliefs can further disadvantage menstruating girls and women.,, Menstruation affects the education of girls, including their attendance, engagement with lessons and potentially their life chances, and research is needed to measure the impact. In the workplace, menstruation affects women’s productivity and absenteeism.

Improving menstrual hygiene management is complex but must begin primarily with education in schools. Currently many girls in LMICs are unprepared for their first period; they often rely on information from their mothers, which tends to be framed in the context of protection from pregnancy rather than the needs and preferences of their daughters.

Adults and hygiene: a focus on slums

The world is becoming increasingly urbanised owing to adults being drawn from rural areas to towns and cities. Over 90% of this urban growth is occurring in LMICs, where the number of urban residents is growing by an estimated 70m each year, and many will end up in urban slums. The number of urban slum dwellers stands at over 880m and is growing. High-density living conditions, poor housing, low incomes, lack of convenient access to affordable clean water and soap, and lack of effective solutions for sanitation and solid waste management mean that the people in these communities are particularly vulnerable to infectious diseases. Currently, opportunities for interventions to reinforce the importance of hygiene behaviour during adulthood are limited, especially in informal settlements. Innovative slum improvement initiatives are required, with the full participation of slum residents.

Older people and hygiene: a focus on respiratory hygiene

Deaths from lower respiratory tract infections are highest in the under 5 and over 70 age groups, and most of this burden occurs in countries with low socio-demographic development. 

The covid-19 pandemic of 2020 has highlighted the particular risks posed to older people by respiratory disease. For example, until December 23rd 2020, 92% of covid-19 deaths in the US had occurred among those aged 55 or older, and only 0.2% in the under-25s. As countries have grappled to contain the pandemic, it has also become clear that there needs to be greater consideration of and emphasis on hygiene standards for preventing respiratory diseases. Hygiene interventions generally put particular importance on behaviours that reduce diarrhoeal diseases, particularly washing hands after using the toilet and before eating, rather than regular cleaning and disinfection of frequent touch points, cough etiquette and washing hands when entering or leaving a different environment.

Our understanding of the basic science of respiratory pathogen transmission pathways and how to interrupt them also needs to be improved. More attention to hygiene during pandemics and epidemics has been shown to have benefits for reducing the incidence of other infectious diseases. For example, from March to September 2020 there were 7,029 influenza notifications in Australia, compared with an annual average of 149,832 over the same period in the previous five years.

A life-course approach to hygiene: understanding burden and behavioural changes is a report produced by The Economist Intelligence Unit and sponsored by the Reckitt Global Hygiene Institute. This research covers the factors that need to be considered to establish good hygiene practices and behaviour, with a particular focus on four areas: diarrhoea, slums, menstrual hygiene and respiratory hygiene. Extensive evidence was gathered from the literature and 11 expert interviews were conducted to help inform our research and this report. Our thanks are due to the following for their time and insights (listed alphabetically): 

Kelly Alexander, senior learning and influencing advisor, Water+, CARE, Atlanta, Georgia, US

Jason Corburn, professor at the School of Public Health and Department of City and Regional Planning, and director of the Institute of Urban and Regional Development, University of California, Berkeley, US 

David Duncan, chief of WASH, UNICEF, Laos

Samayita Ghosh, senior research associate at the Centre for Environmental Health, Public Health Foundation of India, India

Julie Hennegan, research fellow, Maternal, Child and Adolescent Health Programme, Burnet Institute, Melbourne, Australia; adjunct research associate, Johns Hopkins Bloomberg School of Public Health, US

Karin Leder, professor of clinical epidemiology and head of the Infectious Diseases Epidemiology Unit at the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

Stephen Luby, professor of medicine (Infectious Diseases & Geographic Medicine) and director of research at the Center for Innovation in Global Health, Stanford University, California, US

David Nabarro, co-director of the Imperial College Institute of Global Health Innovation, London, UK; special envoy to the World Health Organisation (WHO) director-general on COVID-19; and strategic director of 4SD (Skills, Systems and Synergies for Sustainable Development)

Poornima Prabhakaran, additional professor, head (environmental health) and deputy director, Centre for Environmental Health, Public Health Foundation of India, India

Ian Ross, economist and PhD student (health economics), London School of Hygiene and Tropical Medicine, UK

Joy Ruwodo, director, public affairs for the Ending Neglected Diseases (END) Fund Africa Region

Hygiene refers to the practices that help to maintain health and prevent the spread of diseases. While good hygiene is primarily about behaviours, the ability to practise them well is supported by having the appropriate infrastructure in place, such as access to clean water and soap.

Poor water, sanitation and hygiene (WASH) increases death rates and ill health, creates greater demand for healthcare interventions, widens social inequalities, and has repercussions for quality of life and the wider economy.

There are two main transmission routes for infection—the faecal-oral and respiratory pathways—and hygiene measures work by disrupting them.

Attaining good hygiene is complex, and it is becoming increasingly clear that a more holistic approach is needed that engages and empowers local populations, and is locally sensitive and sustainable.

The life-course approach, which has its origins in preventing or reducing the impact of non-communicable diseases through encouraging good behaviours while recognising the contribution of other factors, including environmental ones, could provide a useful framework for communicable disease and hygiene. Looking at hygiene through a life-course lens could form part of a smarter approach that embeds good hygiene behaviour from childhood (to gain the most cumulative benefit), and then reinforces it throughout a person’s lifetime to boost good hygiene practices if these start to wane.

The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.

These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit. 

This paper looks at the ways in which Sweden has implemented VBHC, the areas in which it has faced obstacles and the lessons that it can teach other countries and health systems looking to improve the value of their own healthcare investments.