Children's ideas and practices concerning hygiene and disease transmission

Exploration in a rural town in Benin

Miranda van Reeuwijk

Abstract

In Benin, likemany other Sub Saharan countries, diarrhoea is one of themost prevalent childhood diseases and one with a highmortality rate. Important factors contributing to this high prevalence are a lack of safe water supplies and sanitation and practices of poor hygiene. Because of the household tasks children are involved in, children can have an important influence on the transmission of diseases. They can form a risk group in the transmission of diseases and diarrhoea or help to prevent diseases, depending on their knowledge and ideas about diseases and their hygienic behaviour. Therefore it might be important, for instance for hygiene promotion programs, to obtain knowledge about the ideas of children concerning diarrhoea and disease transmission. This study records the ideas of children in Tchetti, Benin, regarding the topics of dirt, hygiene, disease transmission, diarrhoea and other (gastro-intestinal) diseases and consequences for the practices children display that influence the transmission of diarrhoea.

In the past, children have been viewed by anthropologists as being continually assimi- lating, learning and responding to adults, having little autonomy, contributing nothing to social values or behaviour except for the latent outpourings of earlier acquired experi- ences (Hardman 1973). According to this view, children are transformed over time into mature, rational adults, but until then children are seen as culturally incomplete. As a consequence, research about children mainly focussed on child-adult interaction while child thoughts and social behaviour were interpreted in adult terms (see for example Caputo 1996, Christensen 1998 & 2000). Furthermore, children were and still are com- monly believed to lack the communicative, cognitive and social skills that are the pre- requisite of good respondents (Christensen et al. 1999). In addition, there are the practi- cal and methodological problems in conducting interviews with children, such as the problem with language use, literacy and different stages of cognitive development. There is a concern about the quality and reliability of the data obtained because children might have a rich imagination and thus embellish accounts, or might be influenced by the power relation between the researcher and the child. In addition, the issues of confi- dentiality and ethics are important when interviewing minors (Christensen et al. 1999).

Only recently has a shift in the ideas about children taken place and anthropologists have become aware of the fact that the aforementioned perspective leaves the under- standing of children as social persons with their own experiences, perceptions and ac- tions in the social and cultural world, more or less, unaddressed (Christensen 1998). Focusing on children’s constitution of knowledge, some studies have concluded that children do contribute to the development of their own identity and are actively en- gaged in the production of their own social world (Caputo 1996, Helman 2000). Their ideas do not necessarily reflect early development of adult culture (Hardman 1973). Also, with regard to ideas and understandings of illness, what causes it and how it should be treated, these studies made it more plausible that children have their own unique ideas and that, like adults, their ideas often have a very clear internal logic, even if they are not scientific (Helman 2000). Furthermore, modern psychological and medical evidence suggests that children are more reliable as witnesses than previously thought and reliability can be increased by skilful interviewing (Christensen et al. 1999). Because of the recent onset of child-centred research, data and literature about children’s perceptions of health, illness and related topics are scarce.

This paper is a first attempt to explore the ideas and practices of a group of children in a West-African community concerning the topics of dirt, hygiene, disease transmis- sion, diarrhoea and other (gastro-intestinal) diseases. The importance of focussing on these topics is that these ideas might influence children’s hygienic behaviour and prac- tices which, in turn, have consequences for the transmission of diarrhoeal diseases, one of the most prevalent childhood diseases in Sub-Saharan Africa and one with a high mortality rate. Having knowledge about the ideas and practices of children might prove to be important for hygiene promotion programmes. If programmes can develop hy- giene improving education which is focused on children and built on children’s ideas, they could have a direct positive effect on the health of the children themselves and an indirect positive effect on the health of others.

The emphasis of this research is on the biomedical construction of hygiene, with hygiene defined as the practice of keeping oneself and the environment clean in order to prevent diseases. However, one should be aware of the anthropological perspective on hygiene, which takes the social and cultural foundations in consideration. After all, motives of hygienic behaviour do not only lie within the avoidance of diseases, but also in complex social rules of cleanliness and dirt avoidance, which influences the practice of hygiene, whether people believe in germs and microbes or not. Unfortunately, research constraints did not provide adequate time and resources to include a specific focus on the social and cultural aspects of hygiene and could only briefly touched upon.[note 1]For relevant literature on the subject of socio-cultural foundations of hygiene, see Curtis 1998, Curtis et al. 1999, Douglas 1970, Ndonko 1994, Zweegers 2002.

The main objective of this study is to record children’s ideas on the topics of dirt, hygiene, disease transmission, diarrhoea and other (gastro-intestinal) diseases and the observed practices that influence the transmission of diarrhoea. The documented ideas are analysed on their construction and how they relate to the relevant practices. Because of the limited time and resources, the study was designed and executed as an exploratory and mainly descriptive study.

Research strategy

This article is based on anthropological fieldwork in Tchetti, a rural town in the south-west of Benin, on the border with Togo, during a period of seven weeks. Most data was collected through the techniques of participant-observation and ethnographic interviewing. More than forty children were interviewed and most interviews were in-depth in nature with either individual children or with small groups of children (up to four children per group). At the end of the research a Focus Group Discussion took place with approximately 12 children. The informants were kept anonymous. The Focus Group Discussion and all except one interviews were taped and transcribed. The research was conducted with the help of an interpreter.

Interviewing children and the advantages and disadvantages of being a white stranger

The name of my interpreter was Hugues, a 30-year-old who was one of the broadcast- ers of the local radio station. Although I was apprehensive that my interviewees would be intimidated by Hugues due to his occupation and age, the children overall responded well to him. In the beginning they were a bit hesitant and suspicious, but then they quickly appreciated the situation and attention given by two ‘important’ persons, the radio broadcaster and a white researcher. They seemed eager to give their opinion about inquired issues and liked showing off to their friends that they were important enough to be interviewed to assist us in an important research project. At one point, children even started to approach us in the community or at home to ask if they could help us. The fact that I gave away balloons and pens, that I liked to play soccer and organised water balloon fights, might have something to do with their motivation.

Being a white stranger in the community helped me to attract children because the foreigner status made me intriguing for them from the start. I had no problems whatso- ever coming in contact with them. From the moment we entered our new house in Tchetti, we were surrounded by children. The neighbour kids helped us with sweeping the rooms, fetching water and buying kerosene for the lanterns. When I unpacked my soccer ball and asked them if they wanted to play a game with me, they were very happy to do so. The neighbour children brought friends to play along and this marked the beginning of my initial contact with my first informants (snowball method). Other in- formants were encountered on the street, while we were walking through the different areas of Tchetti. We would start an informal conversation and naturally progress to reaching topics of research interest. If the child or children were relatively comfortable and talkative, I asked them for their permission to tape the conversation to be able to lis- ten to it again more carefully. Most of the time I showed how the tape recorder worked and let them play with it for a while. When the interview commenced, I attempted to keep the questions simple so that they were easy comprehensible to the children. On the whole, they were very capable of answering even the more difficult questions, did not appear to mind probing their responses, and were willing to explain things to me repeatedly if necessary. Being an ignorant stranger in their eyes made it easier for me to ask for detailed explanations and have ‘weird’ questions. For example, they did not mind in- forming me about how and where they defecated and what they used to wipe their bot- toms. I could ask them why they were embarrassed if they saw someone else defecate, or why they considered dirty things dirty. I heard Hugues using the word yovo when he translated my questions for the children, thereby emphasising that the ‘white stranger’ wanted to know how things were with them. Sometimes they had to laugh since I, the foreigner, did not know why things were dirty which were obvious through their eyes. Although, they shared that they could imagine that things were different in my country (sometimes they even asked about that) and therefore explained things to me in detail, trying to make me understand ‘their ways’. Moreover, using ‘real life’ examples, made it easier to talk about certain things. For instance, I used to tell them that I had become sick myself in Tchetti and if they could tell me how I got diarrhoea. It seemed they liked to hypothesise about the causes and also liked to ‘be consulted by the yovo about things she is ignorant of and they have knowledge about’.

Along with the advantages of being a white stranger came the few disadvantages as well, of which the biggest was that I could never become ‘invisible’. If I wanted to participate in something, like fetching water or even games, they would always notice my presence and start to ‘show off’. Even if the children did not notice or forgot about my presence, which was rare, there was always somebody else who would point me out again. So in that sense, I could not fully conduct much participant observation since their behaviour was noticeably influenced by my presence. Another problem was the fact that the girls were by far not as talkative as the boys. Especially when we interviewed girls in the presence of boys, they did not share as willingly and could not answer the more difficult questions as did the boys. They were also more intimidated by Hugues than were the boys. To be able to acquire information from girls, I had to make sure that during the interview, there were no males around other than Hugues. Then we had to slowly and carefully try to make the girl(s) feel comfortable to talk freely, which most of the time took considerable effort and did not always work out. It became obvious that most girls in the culture were not encouraged to express their thoughts and ideas, even more than children in general, especially in the presence of males.

The final problem was that the presents that I gave to the children to thank them for their co-operation, were regarded by adults as too valuable for them. A few times I saw parents or an older brother take away the pen from the child I had just interviewed. I had not foreseen this problem and felt bad for these children whose token of appreciation it was intended for.

Tchetti and its childhood diseases

Tchetti is a rural border town with approximately 14000 inhabitants and growing. The inhabitants of Tchetti have many different ethnic and religious backgrounds. Most of the people are involved in agriculture or small business like petty trade.

According to many inhabitants Tchetti has two major problems; it has no running water or fresh water sources and there is no electricity. The people in Tchetti are de- pendent on wells and the three water pumps in town for their water supply. Because Tchetti is situated on an elevated plain and on rocky ground it is difficult to bore for groundwater. Due to the lack of a fresh water source most people are dependent on rain water. If it does not rain for a few weeks the water in most of the wells starts to become turbid.

Besides the lack of electricity and water, a major problem, at least for health, is the lack of sanitation. There are only a few latrines in Tchetti. The vast majority of the in- habitants does not have access to a latrine and defecates in certain areas near the moun- tains or in the bush. The poor water and sanitation situation contributes to a consider- able number of health problems in Tchetti. The major childhood diseases seen by the local doctor were diarrhoea, malaria and respiratory infections. The main causes of di- arrhoea in children he diagnosed, were Candida Albicans, an opportunistic yeast infec- tion, and Giardia Lamblia, an intestinal parasite of the protozoa type. In Tchetti, the food and water is often populated with Candida yeast. Because many children suffer from immune depression, caused by the low quality of the food and by the fact that they suffer from repeated illnesses, they become more susceptible for opportunistic infec- tions such as Candida.[note 2]Candida and Giardia were the most diagnosed causes of diarrhoea, but this does not mean that these were the main causes of diarrhoea. Through microscopic examination, yeast and parasites are relatively easy to diagnose. However, it is more likely that most cases of diar- rhoea are caused by bacteria and viruses, like campylobacter, E.coli, rotavirus and Salmo- nella, which mostly go undiagnosed.

The Giardia parasite is spread through water and food contaminated with the cyst of the parasite. Because there is no running water in Tchetti and people drink water from stagnant water sources without treating the water with disinfecting chemicals or boil- ing it, many people in Tchetti get infected. They often become asymptomatic carriers, but many also get diarrhoea, especially the children. The poor sanitary situation in Tchetti is a facilitating factor for diarrhoea causing agents to spread easily. People have to defecate in the bush where they have more of a chance of coming into contact with other people’s and their own defecation, spreading diseases by way of the faecal-oral route. The defecation sites are nurseries for flies that bring and spread diseases to the people. There is also a problem of parasites that are transmitted by means of the feet of people who step into infected faeces. In addition, amoebas are transferred from the stagnant water in the foliage, to the anus of people using leaves to wipe their bottom.

According to Tchetti’s doctor an important reason many children die of diarrhoea is because of parent negligence. According to him, the parents think diarrhoea is caused by bad food, try to treat the child themselves at home and often do not bring the child to a doctor or a hospital until the situation worsens to where the child is suffering from de- hydration, anaemia or even convulsions. Many parents use decoctions of boiled plants and leaves to treat their children’s diarrhoea. If that does not work they go to the market to buy medicine, often an antibiotic or antihelminthic drug, depending on the advise of the market salesman or saleswoman and not on the results of a lab test or on the advise of a health worker.[note 3]The antibiotic most often bought at the market and named by the children, concerned red and black capsules. Those capsules are most likely the antibiotic Amoxycilline.
 If these drugs fail to work, and the situation becomes worse, the parents finally seek the help of a modern or traditional healer. If the modern or tradi- tional healer cannot find a cure either then they refer the patient to the other, or to the hospital. Biomedical doctors and health workers then are often confronted with the problem of resistance against antibiotics, the most serious consequence of people buying antibiotics at the market without the advise or a prescription of a knowledgeable specialist.

Children’s ideas about the causes and contagiousness of diarrhoea: The concept of kokoro

All the children interviewed, without any exceptions, thought that diarrhoea was caused by ‘bad’ food (spoiled food, food not cooked well, unfamiliar food, mixed foods and too much food). These types of ‘bad’ foods did not ‘fit’ the stomach or could not be ‘accepted’ by the stomach. In the case of dirt, defecation or bad smells entering the stomach (by dirty hands or contaminated food or water), ‘other’ sicknesses were said to arise like vomiting, constipation, stomach-ache;only in a few cases was diarrhoea mentioned as a consequence.

To the inquiry of why one becomes sick when dirt enters the stomach or when one smells the dirt, the children explained that the dirt and its smell, ‘disturbs’ the stomach; the stomach cannot ‘accept’ the dirt or the smell and would ‘fight’ it. This resistance causes stomach-ache, constipation and vomiting and was also given as a reason to not share food with a dirty person in addition to stressing the importance of washing your hands. The smell of dirt seemed to be perceived as a very important cause of diseases including diarrhoea and was mentioned by the majority of the children. Although I argued that smell is an element which functions in the air and therefore enters the lungs and not the stomach, they persistently tried to convince me that smell enters and upsets the stomach.

The children stated that you have to wash your hands after defecation because while wiping your bottom, your hand could have touched the defecation. Then, if you eat with that hand, the defecation can enter your stomach along with the food. For the same reason that the stomach cannot accept ‘bad food’, ‘bad smell’ and dirt, it cannot accept faecal material either. I asked them why the stomach cannot accept defecation, even though it originates from there. Some of them said it was because of the “bad smell of the defecation”; others said “defecation is something that you send away from your stomach and when you send it back, it will cause you problems”. During the Fo- cus Group Discussion, a child stated that “defecation is all those things that are not good for the body. You defecate to get rid of them. If such a thing gets into your stom- ach, surely it will cause you sickness”.

One of the first informants shared that the defecation that enters your stomach due to a failure of washing your hands or due to flies transferring it onto food, will turn into invisible worms inside your stomach. It is these worms that cause stomach pain and make one sick. The boy used the Ifè word kokoro (local language) when he talked about the worms. In later interviews the word kokoro returned many times, but its exact meaning remained uncertain in the beginning. It mainly came up during conversations about flies, being another route through which defecation could enter the stomach. Flies, children explained, sit on defecation and then fly to food and land on the food or on plates and transfer the defecation from their legs to the food. One of the children revealed that if the defecation came from a sick person, then the sickness could also stay alive inside the defecation of that person. If you swallow a bit of this defecation, you ingest that sickness as well and you would become sick too. Yet, as he explained, this was only applicable for ‘other sicknesses’ like stomach ache, not for diarrhoea. Some children told me it was not only human defecation the flies brought to the food, but once the flies make contact with the food, they defecate on it themselves as well, causing the same problems for the stomach as human defecation would do.

In two separate interviews there were two children (a ten-year-old boy and an eight-year-old girl) who mentioned microbes as an agent that could be causing dis- eases. They told me that microbes are inside dirty things, that they are invisible and could be carried to food by flies or hands, causing diseases like cholera and stomach ache. At a later point in the interview with the boy I became confused because he was using the words microbe and worm interchangeably. When I asked my interpreter for an explanation, he said the boy was talking about kokoro, something he translated with the English word worm, while the boy himself at the same time was using the French word microbe, which was translated by my interpreter with the English word microbe. He told me the boy was using these two words as synonyms. In the other interview with the girl, she was using the French word microbe and I asked her to explain the defini- tion of microbes. She told me microbes give diseases to people, they are everywhere, mainly in dirty things and that “if there is sand somewhere and you pour water on it, it becomes microbes”. A minute later she described microbes in a somewhat biomedical sense, but then used the Ifè word bibi, which was translated by my interpreter with the word worms (which I had thought was kokoro in Ifè). I asked her what the difference was between bibi, microbes and worms and she told me those were all dirty things, but could cause different diseases. She could not explain the exact differences or similari- ties, so I turned to my interpreter for an explanation. He told me that bibi means small ants and that it was, as he said, Ifè ‘slang’ for kokoro. According to him, both the girl and the boy made the mistake to translate it with the French word microbe, while they were really talking about worms. In a later interview with an adult, the adult used the word kokoro and translated it himself with the French word insect. It was then that I understood that kokoro actually means insects that cannot fly, insects without wings, thus including ants and worms.

Several children told me flies carry kokoro from defecation to food. The following transcription is an excerpt of one of the interviews with the children. The M in front of the sentence represents my question or remark, the H stands for Hugues, my inter- preter, translating the child’s answer. Because it is a literal transcription, we are talking about the child or children in the third person.

H There are some worms (kokoro) inside the flies. By the time they sit on the defeca- tion of somebody else, they carry those worms and sit on the food in somebody’s house. That will cause sickness.

M Exactly how do they cause sickness?

H The worms will get inside the food and they get in your body and they can cause pain and diseases.

M Can you see these worms?

H The worms inside the flies are white and you can see them.

M But then you can see that they are in your food and you will not eat it?

H If they are on top of the defecation you can see them. But by the time the flies bring them to the food, you cannot see them.

In other interviews I learned that several children thought that defecation, after being excreted in the bush or the latrine, becomes sand or worms (again the word kokoro was used). This might explain the ideas of the boy quoted earlier, that defecation inside the stomach turns into worms. They described the worms on the defecation as white, visi- ble worms that are brought there by flies or come out of the mud and turn into flies themselves, after they have eaten the defecation.

Again, it should be emphasized that most children, when they were talking about diseases caused by dirt, defecation, smell or kokoro entering the stomach, they were talking about “other” diseases like stomach ache, constipation and vomiting. Only a few children added diarrhoea to this list, but that was only after they were questioned directly if it could also cause diarrhoea.

Although the children were quite cognisant of the faecal-oral route of disease trans- mission all the children, without exception, said that diarrhoea is not contagious. Ini- tially I found that very confusing, as the next quote of one of the interviews shows:

M If, let’s say, his brother has diarrhoea, and that brother did not wash his hands after defecation and with that hand he touches things in the house and then he (the inter- viewee) will come and touch the same things in the house, can he get diarrhoea then?

H It might not give you diarrhoea, but it might cause another sickness.

M What other sickness?

H Constipation.

M Why?

H By the time you eat together with such a person, that food will not fit you and will give you another sickness like constipation and you feel like throwing up.

M Is it always that all the next times that you eat that particular food, it makes you ill?

H Only for the first time, you will throw up, after eating with such a person you will throw up, but if it goes on like that, after some time eating with such a person it will give you another illness, like constipation.

M But only if you eat with the person who is sick?

H aha… ask it again (my interpreter is confused).

M He said, that if you eat with someone who has diarrhoea, you will not get diarrhoea, but you will get other sicknesses. I asked why and he said it was because of the food, that the food did not fit him well. But that has nothing to do with the guy he is eating the food with, the guy who is sick. So I wonder, if the sick person is not around and you eat that particular food that does not fit you, you become ill, that is what he said before. But how, what, what does that person do that you share your food with, how does that make you sick, because that has nothing to do with fitting food or whatever.

H It’s because the person who is sick with whom you eat, his hands are dirty. By the time you eat, even if the food fits you and the food is good for you, you don’t have any problems with the food. But for the part that you eat with such a person, a person who’s hands are dirty, it is for that reason you become ill.

M But if that person has diarrhoea, and he has dirt on his hands, and you get that dirt in- side you, why do you get another disease and not diarrhoea?

H What causes the diarrhoea for him, you don’t know. You don’t eat that… if that is the food, you don’t eat that food, so it cannot cause you diarrhoea. Because you don’t eat the same food. You don’t know what food caused him diarrhoea. So by eating with him, without washing his hands, that one cannot give you diarrhoea, it can give you another illness.

M Aha! Because it is two separate things. There is the dirt, it does not matter if the per- son is sick or not, that can cause the illness.

H (after translating for verification) Yes.

It took some time before I understood that swallowing a bit of diarrhoea does not give one diarrhoea because it contains noxious agents of some kind, but that it gives other diseases like stomach ache, vomiting and constipation, because diarrhoea is defecation and defecation causes “other diseases”. The only thing that can cause diarrhoea is “bad” food and therefore diarrhoea itself is not contagious. The “other diseases” on the other hand can be transmitted from person to person by means of flies, worms (kokoro), hands, dirt, defecation and smell.

Preventive practices and motives for hygienic behaviour

Since the children I interviewed perceive diarrhoea to be caused by “bad” food, it is not hard to understand that they said diarrhoea is preventable by the avoidance of eating the food that caused diarrhoea in earlier episodes. If the diarrhoea was caused by eating too much, then you simply had to eat less, they said. Furthermore, you should take care not to mix your food, not to eat food that is not well-cooked or that is left over for more than a day. It was also said to not drink water that has been stored for more than four days.

The children told me you could prevent diseases by washing your hands after defe- cation, before eating and by covering food and water. You should take care not to touch somebody else’s defecation, which is why you should always wear flip-flops when you go to the bush to defecate. This was also one of the reasons why the children did not like to go to the bush at night; at night you cannot see the other defecation. They ex- plained that it is better to stay at the border of the bush, dig a hole and cover the hole again after you have defecated. Some children said they defecated near the house at night, if they really had to go, but made sure that they threw the defecation in the bush first thing the next morning. All the children, whom I asked which was more prefera- ble, the bush or the latrine, said the latrine was better because there was less of a smell, fewer flies and a smaller chance of touching somebody else’s defecation. Besides, in the latrine you did not see the defecation like in the bush, which was also better.

Finally, you should keep an eye on little children and prevent them from defecating near the house or on the street.

Avoiding sickness by cleaning up dirt and avoiding faeces is not the only motive for hygienic behaviour. As said before, smell, although rationalised as causing diseases, is a motive too, probably stimulating hygienic behaviour by triggering the feeling of aversion or the emotion of disgust. Furthermore, as stated a couple of sentences above, it is also better not to see defecation, probably for the same reasons. Yet another motive could be found in the socio-cultural foundations of dirt and hygiene. The children fer- vently described the social consequences of not cleaning and being dirty or having a dirty house: people would run away from you, yell at you or start to insult you. You would feel embarrassed and they might start to gossip about you. Children would react the same way if they would enter a dirty house or encounter a dirty or defecating per- son. It is interesting to notice that encountering a defecating person or being encoun- tered while defecating leads to embarrassment not only because of the situation, but mainly because of the embarrassment for the smell.

The ideas children have about the causes and transmission of diseases and the fear of punishment or shame for not being clean, have important consequences for practices regarding dirt and hygiene. Although diarrhoea was not conceived of as being conta- gious, the aversion of faeces, the ideas about smell as causing diseases and the notion of other (gastro-intestinal) diseases as being contagious, resulted in several beneficial preventive practices.

Household tasks and the importance of knowledge of the ideas of children concerning diarrhoea and disease transmission

In low-income countries children start to participate in social and economic roles at an early age and often serve as a source of income for their families. This is an important reason why the concept of childhood in developing countries differs from that in devel- oped countries, where the leading opinion about children is that they should have a pro- tected and untroubled childhood with the opportunity to go to school and play. Children in developing countries, on the other hand, resemble young adults and often have important responsibilities in the household, which include fetching water, prepar- ing food, looking after younger siblings, but also helping to care for the ill. Because of these tasks and responsibilities, children can have an important influence on the trans- mission of diseases, negatively as well as positively.

Therefore, it is beneficial to obtain knowledge about the ideas of children concern- ing diarrhoea and disease transmission because children might form a risk group in the transmission of diseases and diarrhoea, but they could also help to prevent diseases if they themselves have knowledge about preventive practices. If we look at the house- hold tasks that are named and performed by the children, e.g. sweeping rooms, fetching water, washing dishes and clothes, helping to prepare food, working in the fields and assisting in the care-taking of younger siblings and sick people, it seems that children are directly linked through these tasks with the routes of transmission of contagious diseases, especially diarrhoea. Many children are involved in cleaning chores, getting rid of dirt, washing, sweeping etc. and therefore they also directly come into contact with disease causing agents and help to prevent these agents from spreading at the same time. If children are unaware of the risks and of good hygienic practices, they could unintentionally contribute to the spreading of diseases like diarrhoea to them- selves and to others. This also applies to tasks like fetching water and helping to pre- pare food; sources that, once they become infected, could spread diseases to whole families. Farming (through which children come into contact with manure of animals and humans) and helping younger siblings with going to the bush to defecate to help them wipe, might influence disease transmission as well; positively if the child is aware of the risks and preventive measures, negatively if the child is unaware or indif- ferent about them. In the case of the children with whom I spoke, the children were pretty much aware of risky behaviour, ways of transmission and ways of preventing transmission. Although the details about the agent that causes the diseases varied a bit between the children, and from biomedical explanations, the main ideas about ways of transmission were similar to biomedical notions and therefore hygiene practices made sense to the children and were practiced accordingly. The fact that diarrhoea was not perceived to be contagious did not negatively influence their practices, because pre- vention and hygienic behaviour were carried out to prevent “other” diseases, thereby forming a barrier for the transmission of diarrhoea as well.

Like adults in their own society and in other societies the children rationalised their hygienic behaviour, saying it was practised to avoid dirt since dirt can cause diseases. They did not only try to avoid touching dirt, they also tried to avoid smelling and seeing it. In whatever way hygiene behaviour is rationalised as disease prevention, the emotion of disgust and the aversion related to dirt, plus the social forces and consequences related to cleanliness and dirtiness, form powerful motivations for hygienic behaviour as well.

These examples show how important it is to have knowledge about the ideas of children concerning disease causation and transmission and their ideas about the social consequences of being dirty or lacking hygienic behaviour. If their ideas do not lead to hygienic behaviour or if they are indifferent about it, then children could form a serious (and large) risk group in transmitting diseases to themselves, each other and others. It seems that it would therefore be worthwhile for prevention programmes to focus on this group of the population and adapt their programmes to the ideas, knowledge and already existing beneficial practices of children.

Conclusion

This research was performed with the aim to take the children’s point of view, with the assumption that children do not simply reproduce adult information, but are actively involved in the production and formation of knowledge and ideas. Considering the information described above one could see that the information given by the children has an internal logic and is coherent. As respondents they have provided reliable, meaningful and useful information.

The children perceive diarrhoea to be caused by ‘bad’ food and is therefore not understood as being transmittable per se. Other gastro-intestinal diseases, like vomit- ing, stomach-ache and constipation, are in contrast seen to be caused by invisible worms (kokoro), microbes and smell, originating from dirt and defecation and reaching people directly or indirectly via hands, flies and food. These other diseases are there- fore thought to be contagious.

Several hygienic practices were mentioned and executed by the children. These in- cluded hand washing, cleaning up dirt and avoiding faeces. Reasons for this hygienic behaviour were to avoid sickness and smell (which was thought to cause diseases), the aversion of dirt, defecation and the emotion of disgust that was triggered by it, and be- cause of the social consequences of not cleaning (the negative reactions of others and the feeling of embarrassment). Although diarrhoea was not conceived to be contagious per se, the hygienic behaviour practised to prevent the other diseases, and the socio- cultural forces, formed a barrier to the spread and transmission of diarrhoea as well.

Considering the household tasks in which the children were involved, the children formed an important factor influencing the transmission of diseases. Because they were fairly aware of risky behaviour and ways of transmission, the children behaved hygieni- cally and therefore helped in preventing disease transmission. If the children were un- aware or indifferent about these practices, then they would form a large risk group in the transmission of diseases and diarrhoea to themselves and the community at large.

Because children can form a large risk group in the transmission of diseases but can just the same be beneficial, active agents in disease prevention, they form an important group to focus on in prevention programmes. For such programmes to be effective they should understand the ideas and practices of children concerning disease transmission, diarrhoea, dirt and hygiene.

In the case of Tchetti, the high prevalence and mortality of childhood diarrhoea is more likely to be a result of the lack of sanitation, the lack of safe drinking water, the moderate health condition of the children (weakened immune systems), the antibiotic resistance and the therapy seeking behaviour of the parents than as a result of a lack of knowledge and performance of hygienic behaviour. The ideas children had about dis- ease causation and transmission, the aversion of dirt, defecation and the smell of it, and the social motivation for hygienic behaviour together with the inconvenience of having to defecate in the bush, made latrines popular with these children. There seems to be sufficient grounds to believe that latrine programmes in Tchetti would be successful and would form an important factor in improving health and preventing diseases like diarrhoea.

Notes

Miranda van Reeuwijk, Master in Medicine and Medical Anthropology, worked for IREWOC, the Amsterdam Foundation for International Research on the Exploitation of Working Children. She studied “Children as agents in development” in Tanzania. The article above is based on her thesis (Van Reeuwijk 2001) in Medical Anthropology at the University of Amsterdam.

I want to thank the people of Tchetti for their hospitality. I especially want to thank my infor- mants, the children, for trusting me and for all the fun we had. I thank Hugues for interpreting and explaining, my colleagues LeAnna Fries (for editing my work – again –) and Jennifer Fagan (for taking me to Africa), and my family and friends for allowing me to go and for their support. Finally I want to thank my supervisors and teachers, Sjaak van der Geest and Ria Reis, for their guidance and enthusiasm.

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