The Dirt on Hand Hygiene Research Projects in Africa
by Helena Scutt. Helena is a sophomore with an interest in the intersection of water, sustainability, and public health.

June 14, 2011 11:02 am

The second-largest killer of children under five is easily preventable and treatable (read more), yet it kills 4,000 children each day. This killer, diarrheal disease, causes death by severe dehydration, and especially affects young children due to their weakened immunity and high surface area to body mass ratio.  During the 1980s and 1990s, improvements in access to sanitation, oral rehydration solution, and clean water greatly reduced diarrhea-related deaths (read more). However, preventable child mortalities resulting from diarrhea still occur, particularly in areas of the world with limited access to clean water.

Many people do not have dependable access to clean water.

In efforts to address this problem, Stanford’s aptly named ‘Poop Group’ researches the intersection of water, sanitation practices, and public health under the leadership of Dr. Jenna Davis.

Recent Stanford graduate Annalise Blum (B.S. Environmental Engineering, 2010) and Fulbright scholar Jessie Liu (B.A. Human Biology, 2009) are alumni of the Poop Group. Along with Stanford PhD candidate Amy Pickering, Blum and Liu have worked on projects that focus on the importance of contaminated hands in transmitting diarrhea-causing pathogens.

Annalise Blum (B.S. Environmental Engineering, 2010)

Blum, who worked in Kenya and Tanzania, and Liu, who worked in Tanzania, gave the Stanford Journal of Public Health insight into their experiences, highlighting the challenges of investigative public health research in the developing world. Each of their perspectives reveals setbacks, surprises, and lessons learned in research that provide useful advice: when conducting research outside of one’s own culture, nothing can be assumed.  Blum and her fellow researchers had to be flexible with their surveys, avoiding the assumption that a single, fixed set of questions could be used at all locations. In the study that Blum worked on, surveillance cameras were posted in schools in Kibera, Kenya to monitor how often students used alcohol-based hand sanitizer after visiting the latrine.

Blum recounts that her group fully developed their research question and wrote the baseline survey before going to Africa, but that once there, the survey process was not static. “We make changes to our surveys based on conversations with our enumerators [locals hired to conduct the surveys] and results of the pilot-testing in the field.  This helps make the surveys more appropriate to the local context and better at collecting relevant data,” Blum suggested. She further highlights the importance of adaptability in not just the research method, but more broadly, in public health measures with her belief that “there are not one-size-fits-all solutions. Solutions must be tailored to community needs,” which became clearer to her throughout the study.

Like Blum, Liu also found it important to keep an open perspective when doing research in an unfamiliar culture. Liu noted that what surprised her most in her experiences in Dar es Salaam, Tanzania, was the imminence of mortality. She explained, “Our driver [in Tanzania] was shocked that all four of my grandparents were still alive. There was one incident in which our house helper texted us a message one morning, ‘My sista die 2day. Can I come in Wed insted?’ Wednesday was the next day.” The cultural system that had developed to deal with early or unexpected death was striking to Liu and played a role in shaping her thesis research. Nearly everyone, even collaborators with doctorate degrees from the Muhimbili University of Health and Allied Sciences, expressed a certain degree of fatalism and belief in supernatural entities. When revising the survey with input from Tanzanian enumerators, this system of beliefs provided an interesting cultural context for Liu as she assessed the extent to which mothers believe they can control the health of their children.

Jessie Liu (B.A. Human Biology, 2009) in Dar es Salaam, Tanzania

Keeping her assumptions at bay was also essential to Liu when investigating why diarrheal illness is so prevalent in Dar es Salaam. Her study assessed the perceptions, knowledge, and attitudes of mothers when considering the prevention methods they use to maintain a healthy family. Liu, in her Human Biology Honors Thesis,  reports that despite what people might assume, knowledge of disease transmission and diarrheal illness did not correlate with a mother’s decision to perform certain hand-washing, sanitation, water treatment, or Oral Rehydration Salt-use behaviors.

Rather, these health behaviors correlated with the self-efficacy of the mother: her perceptions of whether she could prevent diarrheal illness or control her situation. Liu’s findings emphasize that only implementing educational interventions to address childhood diarrhea may be insufficient. Allowing the research to inform one’s perceptions rather than relying on one’s own preconceptions about why a problem exists is vital.

In both of their projects, Liu and Blum avoided a common mistake in research—the assumption that locals would provide honest and truthful survey responses when questioned by visiting researchers. Blum notes that “in Kibera, a lot of foreigners have come in and made promises they haven’t always kept.  So residents may be hesitant to trust wazungu (foreigners).” Thus the enumerators were vital to both projects because they gained the trust of the participants. Blum emphasized, “anywhere you’re working, have the locals ask the survey questions.” Similarly, in Tanzania, “all enumerators were local or Tanzanians who had already spent considerable time in Dar.” The important role of enumerators suggests that in research of this nature, often who is delivering the survey can be as important as what the survey asks.

Through their experiences, Blum and Liu show us some of the challenges that arise when pursuing investigative research in another culture. They suggest that researchers should be prepared to adapt their approach based on the values and customs of the people in order to develop accurate findings and access real community needs.

Photo credits to Annalise Blum and Jessie Liu.

This article was first published in the inaugural issue of the Stanford Journal of Public Health.  Thanks to the editors and to Helena for letting us share this article with our readers.  We look forward to continuing this collaborative relationship.


Helena Scutt is a sophomore (’14), major undecided. As captain of the Stanford Sailing Team with a love of the water, she is interested in management of water resources worldwide. She enjoys running, snowboarding, and teaching sailing near her home in Seattle. She also writes for the Stanford Journal of Public Health, in which this article was originally published.