Hygiene-related stigma is an under-recognized problem for sanitation interventions

The Global Ethnohydrology project began in 2006, imagined by Amber as a postdoc when she first came to ASU. We have a rhythm to the project, and each year we select a new topic, connect to new collaborators, and work in slightly different countries over the summer. We try to go – quite literally where the questions take us. In the fall we analyze the data and begin to write up. Sometimes it takes a while to figure out the very best way to analyze tricky data, and 2015 was a particular doozie. We collected open ended data in four countries that summer – Guatemala, Fiji, New Zealand, and the US. We were trying to understand how people in different places put stigma – value-laden, socially rejecting, judgements, onto people who can’t meet local norms for cleanliness. This is a real problem for people who are water insecure, because it is nigh impossible to keep yourself, your children, and your house clean if you don’t have enough water to do that.

So, we ended up with something like 24,000 coded segments of text regarding how adult men and women understood the forms hygiene violations took, and talked about how they would judge them. Luckily, Amber knows a lot about text analysis, but it was pretty daunting none-the-less. But in the end we got some very interesting results, published this month in Social Science and Medicine. Basically: in all four of the sites, we found that people who violated local ideas of “being clean” were very harshly judged. People didn’t extend them much in the way of empathy, or imagine their lack of cleanliness was anything short of bad choices or personal failing. Being judgmental of those who are “unacceptably dirty” didn’t seem to be about disease or contagion at all, but rather just about social devaluation.

Global Ethnohydrology Study (GES) interviews in Fiji. Many ASU Global Health students get their first taste of fieldwork through the GES.

Why does this matter? If you want the whole story, you can read the SSM article. But here’s the short version: WASH (water, sanitation, hygiene) interventions in lower income countries increasingly depend on fast, low cost, behavioral intervention methods to get people to build and use toilets and washstands. One of the better know and respected approaches is called Community-led Total Sanitation (CLTS). This and similar sanitation interventions increasingly use disgust (around shit) to “trigger” people into behavior change. The problem is that those who cant afford to build toilets or don’t have water to maintain a wash stand, end up at greater risk of being socially labeled as “disgusting”, i.e., stigmatized, and otherwise humiliated. This is why we argue these types of sanitation intervention should be much better monitored or, perhaps even better, abandoned.

CLTS triggering being done in Volta, Ghana 2014; community members are identifying sites of open defecation.

NOTE: our GES work is part of the HWISE RCN collaboration, led by geographer Wendy Jepson. If you are interested in water insecurity, check it out.