Measuring hygiene practices: A comparison of questionnaires with direct observations in rural Zaire

To date questionnaire surveys have been the most commonly used instruments to measure hygiene behaviours related to water and sanitation. More recently, a number of studies have used structured observations to study practices related to diarrhoea. During a trial of a hygiene education intervention to reduce diarrhoea among young children in Bandundu, Zaire, both instruments were used to measure the disposal of child faeces and various hand-washing practices. Three hundred families were observed and follow-up interviews performed with 274 (91%) mothers. At the individual level, agreement between observed and reported behaviour was little better than might be expected by chance. There was evidence of over-reporting of hand-washing before food preparation (44% vs 33%; P = 0.03), hand-washing before eating (76% vs 60%; P < 0.001) and disposal of the child's faeces in a latrine (75% vs 40%; P < 0.001). On the other hand, hand-washing before feeding the child was reported less often than it was observed (7% vs 64%; P < 0.001). Our data are consistent with the hypothesis that, in general, mothers over-report 'desirable' behaviours. At the same time, our data indicate that open questions may lead to underreporting of certain behaviours. The repeatability of observations at both the individual and population levels remains to be established.