Social Science and Medicine 52 (2001) 53–69
Diffusion of ideas about personal hygiene and contamination
in poor countries: evidence from Guatemala
Noreen Goldmana,*, Anne R. Pebleyb, Megan Beckettc
a
Office of Population Research, Princeton University, 21 Prospect Avenue, Princeton, NJ 08544-2091, USA
School of Public Health, UCLA, 650 Charles E Young Drive South, Los Angeles, CA 90095-1772, USA
c
Population Center, RAND, PO Box 2138, 1700 Main Street, Santa Monica, CA 90407-2138, USA
b
Abstract
In this paper, we explore the diffusion of beliefs pertaining to the causes of childhood diarrhea in rural Guatemala.
The analysis focuses on the importance of interpersonal and impersonal contacts as conduits for information and
norms related to hygiene and contamination. Estimates from multivariate models reveal that there is evidence of a
diffusion process through social contacts, primarily through interpersonal ones. The analysis also identifies striking
differences between (1) the diffusion process related to hygiene (e.g. dirtiness) and that related to contamination (e.g.
pathogens); and (2) beliefs about the causes of diarrheal illness among children in general and those among
respondents’ own children. # 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Diffusion; Hygiene; Contamination; Diarrhea; Guatemala
Introduction
The large and sustained reduction in mortality that
has taken place in virtually all countries in the past 200
years must be counted as one of the most dramatic social
changes in human history. Much of the decline is due to
decreased mortality from infectious causes, i.e. from
diseases that are caused by the growth of pathogenic
microorganisms within the body and that are usually
transmittable to others.
Although there was considerable controversy in the
past about the reasons for this mortality decline,
demographers are now in general agreement that the
declines can be linked to two broad causes: (1) increases
in income and associated improvements in nutrition and
standards of living; and (2) factors generally thought to
be exogenous to income levels, such as public works (e.g.
sanitation systems and water quality improvements),
public health interventions (quarantines, mosquito
*Corresponding author. Fax: +1-609-258-1039.
E-mail address: [email protected] (N. Goldman).
eradication, vaccination), and improvements in therapeutic medical techniques (e.g. development of effective
drugs, adoption of aseptic practice). For example,
Preston (1976, p. 83) concludes that approx. 10–25%
of the growth in life expectancy worldwide between the
1930s and the 1960s was attributable to increases in real
income, while the remaining 75–90% was due to ‘‘the
activities of ‘exogenous’ medical and public health
factors’’. Palloni (1990) reports that results of a similar
analysis for 23 countries in Latin America show that
growth in real income accounts for 45% of mortality
decline in the period 1945–65 and 75% in the period
1965–85.
These explanations generally cast individuals and
families as relatively passive actors in a process
controlled primarily by macro-level forces, including
macro-economic changes and programs developed and
implemented by social and political elites.1 However,
1
Exceptions include recent work by Nathanson (1996) which
considers the role of ‘‘grass roots’’ social movements in the
United States in pushing for and implementing public health
programs.
0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 1 2 2 - 2
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N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
more recently several researchers have suggested that
changes in individual behavior and belief systems made
important contributions to US and European mortality
declines at the turn of the century (Preston & Haines,
1991; Ewbank & Preston, 1990). Others (Caldwell, 1986;
Cleland, 1990; Lindenbaum, Chakraborty & Eias, 1985;
Lindenbaum, 1990; Bhuiya, Streatfield & Meyer, 1990)
have made similar arguments for developing countries.
For example, concerning the decline in infant and child
mortality in the US in the early 1900s, Ewbank and
Preston (1990, p. 143) conclude:
against which children can be immunized (e.g. measles,
polio, diphtheria), immunizations have only recently
become available for the prevention of diarrheal
infection, and are prohibitively expensive in developing
countries. Data for this analysis come from the
Encuesta Guatemalteca de Salud Familiar (EGSF,
also known as the Guatemalan Survey of Family
Health) conducted in rural areas of Guatemala in
1995.
Mortality decline and health beliefs in rural Guatemala
Most accounts of mortality declines since 1850 have
emphasized the roles of improved standards of living,
especially diet, and of vertically-organized government programs such as water supply and sewerage
improvements, mass vaccination campaigns and
antimalarial activities. While we have no doubt that
such changes were important, we believe that a third
set of factors related to health care practices in the
home may also have been a major contributor to the
decline in infant and child mortality.
Preston and Haines (1991) suggest that individual
behavioral change in the US in the early 1900s occurred
because of a change in ideas about disease causation,
specifically the adoption of the germ theory of disease by
the general public.
Historical evidence on changes in personal healthrelated behavior and ideational change in currently low
mortality countries is, of course, quite limited, because
systematic data on individual beliefs and behavior are
generally not available. However, poor countries in
Latin America, Asia and Africa are currently experiencing substantial mortality declines due to reduction in
infectious disease mortality, major changes in beliefs
about illness causation, and potentially important
changes in individual health-related behavior. Surprisingly little demographic research has been done on the
diffusion of innovative ideas about health in these
countries. In this paper, we examine evidence about the
process of ideational change in rural areas of one poor
country, Guatemala. As we describe below, belief
systems other than the germ theory of disease remain
common in rural Guatemala and infectious disease
remains the major cause of death for children. Yet major
changes appear to be underway in beliefs and behavior
related to health.
More specifically, we examine beliefs related to the
determinants of childhood diarrhea, which is a major
cause of death for children in Guatemala today, as it
was in the US at the turn of the century. Diarrhea is
transmitted by fecal-oral contamination, e.g. by
unwashed hands or dirty dishes, and is, therefore,
strongly associated with the level of cleanliness in the
household. In contrast to many other diseases
Guatemala is the largest country in Central America
with a population of approx. 10.5 million in 1995
(CELADE, 1997). Although only 108,889 km2 in size
(INE, 1988), many rural areas remain relatively isolated
from urban Guatemalan life, which is centered primarily
in the capital, Guatemala City. However, improvements
in transportation and communication, the growing
importance of international and rural-to-urban migration, and the increasing role of export industries have led
to rapid changes even in rural areas that were, until
recently, fairly remote.
Guatemala remains a highly stratified society in which
a small elite controls much of the land and economy,
and retains political power. Here again, however, the
situation has changed over the past decade with the
growth of a substantial commercial middle class,
implementation of democratic elections, and the end of
a 30-year long civil war. The population is divided into
two ethnic groups of roughly equal size: the indigenous
population, who are descendants of Mayas and other
pre-conquest groups, and ladinos, who, regardless of
ethnic origin or phenotype, speak Spanish, wear
European clothes, and view themselves as part of the
mainstream Guatemalan culture. Ethnicity is closely tied
to social class: the indigenous population is, with few
exceptions, poor, while ladinos are members of all social
classes.
As elsewhere in Latin America, Guatemalan mortality
rates have fallen since the 1950s, although they remain
among the highest in the region. The expectation of life
at birth rose from 56.4 in 1977–80 to 64.8 in 1990–95
(CELADE, 1997). In rural areas, estimated child
mortality rates (5q0) declined from 129 deaths per 1000
in 1977–87 to 74 per 1000 in 1990–95, compared with a
decline from 99 to 55 in urban areas (MSPAS, INCAP &
DHS, 1989; INE et al. 1996).
Several belief systems about the causes of diarrhea
remain common throughout rural (and to a lesser
extent, urban) Guatemala (see Pebley, Hurtado &
Goldman, 1999, for a review). One theory is that an
imbalance of hot and cold can cause illness, a belief
which is common in Latin America, Asia and, historically, in Europe (Weiss, 1988). Hot and cold qualities
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
apply to foods as well as to activities and emotional and
physical states, and do not necessarily refer to temperature. For example, in Guatemala, beef and sugar are
often considered hot, as is pregnancy and anger, while
drinking cold water, touching cold ground and eating
‘‘cold’’ foods are mechanisms through which excessive
cold can enter the body. A second important belief
concerns the function of worms (lombrices) in the
digestive system. Under normal circumstances worms
are believed to live in a sack in the abdomen and to aid
in digestion, but a serious and potentially fatal condition
can arise when the worms are disrupted, leave their sack,
and travel throughout the body. Our earlier work with
in-depth interviews showed that other beliefs about
causation of diarrhea included improper eating (eating
too slowly, too rapidly or not at the right time), and
causes related to hygiene or dirtiness (Pebley et al.,
1999).
Pathways for diffusion of innovative beliefs
We hypothesize that the primary mechanism for
diffusion of ideas about hygiene is through ‘‘social
contacts’’ both with urban middle-class Guatemalan
society, where the germ theory of disease is much
more widely accepted, and with societies outside of
Guatemala, primarily through migration to Mexico
and the United States. Following the literature on
diffusion of innovation in fertility behavior (Montgomery & Casterline 1996), we distinguish between two
types of social contacts. Interpersonal contacts include
family, friends and acquaintances with whom individuals interact on a personal, and generally informal,
basis. Impersonal contacts include conduits for new
ideas which do not involve personal acquaintance
between two or more people, such as the mass
media and health campaigns and programs. Both
interpersonal and impersonal contacts are hypothesized
to be important conduits for: (1) information
about hygiene, techniques and costs of hygienic behavior, and the role of contamination in illness causation,
and (2) norms about the importance of hygienic
behavior.
Both information and norms are likely to play
important roles in bringing about changes in individual
beliefs and in behavior. Information provided by social
contacts includes basic ideas about how illness is
transmitted, specific hygienic techniques that reduce
transmission and their efficacy, and the time and
monetary costs associated with these techniques. Norms
affect the likelihood that individuals will actually adopt
hygiene-related beliefs and put them into practice.
Hygienic practices can be costly in terms of time and
money, and normative prescriptions favoring hygiene
may spur individuals and families to adopt them despite
55
their costs. Interpersonal contacts (especially those
sociologists refer to as ‘‘strong ties’’2) may play a more
important role in transmission and enforcement of
norms about hygiene, than impersonal contacts. For
example, family members, whose opinions are valued
and whose assistance is regularly needed, may have
more influence in changing individuals’ beliefs or
behavior, or in preventing change. However, research
on fertility change suggests that impersonal contacts,
and in particular mass media, can provide strong
normative messages relating beliefs and behavior to
social status and social mobility (e.g. Bankole, Rodriguez & Westoff, 1996; Westoff & Rodriguez, 1995).
In this paper, we investigate whether there is evidence
of the type of diffusion process through social contacts
that we have sketched above in rural Guatemala. We
also examine the relative importance of different pathways of diffusion of innovation on individual hygienerelated beliefs and behavior. To trace the flow of
information and ideas through a social diffusion process
would require data on all of a sample of individuals’
social contacts including: their beliefs about and knowledge of hygiene, the information and ideas they express
to the sampled individual, the frequency and type of
contact they have with the sampled person, and the
dynamics of their relationship with the sampled person.
Ideally, we would need this information on each person
and each contact at several points in time to examine the
process of change. Obviously, these are data requirements that are difficult for any study to meet.
Instead we use cross-sectional survey data and
examine whether women who have social contacts with
the outside world (i.e. with urban Guatemala or with
other countries) are more likely to believe in inadequate
hygiene as a cause of diarrheal illness and are more
likely to use hygienic practices. Specifically, in the case
of interpersonal contacts, we examine: (1) a woman’s
own social ties outside the community, (2) proxies for
the amount of contact community residents have with
the outside world (i.e. frequency of migration, remoteness, and accessibility of community), and (3) the degree
of involvement of a woman and her family in the
community. As an indicator of community involvement,
we examine whether women or their family members are
active in religious, economic, social, or other community
groups.3 We hypothesize that belief in hygiene as a cause
of diarrheal illness is more common among women who
themselves know people outside the community, and
women who live in communities which have consider2
That is, those with whom social interaction is frequent and
important or with whom social exchange is strong
3
Community groups are common in rural Guatemalan
villages and include agricultural cooperatives, women’s groups,
and cofradias (religious organizations which often have
responsibility for saints’ days and other festivals).
56
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
able contact with the outside world. We also posit that
women who are involved in community organizations
(or who have family members involved in these groups)
are more likely to believe in the role of hygiene because
they are more apt to come in contact with innovative
ideas circulating in the community.
also collected information on pregnancy-related care,
family economic status, social ties, and other topics. In
addition to household and individual interviews, a
community questionnaire was administered to three key
informants in each of the 60 communities and provided
information on economic activities, wages, infrastructure,
services, transportation, migration and other aspects of
community life.
Data and analytic strategy
The EGSF
Measures of hygiene-related beliefs and behaviors
The data for this analysis come from the Encuesta
Guatemalteca de Salud Familiar (EGSF),4 conducted by
Princeton University, RAND, and the Instituto de
Nutrición de Centro América y Panamá in 1995. The
EGSF is a survey of women ages 18–35 carried out in
rural areas of four departments of Guatemala (Chimaltenango, Totonicapán, Suchitepequez and Jalapa). The
sample was restricted to four departments because a
national sample would have necessitated interviewing in
more than 21 indigenous languages spoken in Guatemala. The four departments were selected on the basis of
social, economic, and environmental diversity, and
ethnic composition: one primarily ladino (Jalapa), two
predominantly indigenous (Chimaltenango and Totonicapán) and one of mixed ladino/indigenous population
(Suchitepequez). The two indigenous languages spoken
in these departments, K’iche and Kakchiqel, are two of
the largest indigenous language groups in Guatemala.
The survey is based on a sample of households living
in rural communities (i.e. communities with between 200
and 10,000 inhabitants). A total of 60 communities were
included in the survey, 15 in each of the selected
departments. The sample was designed to be selfweighting within (but not across) departments and to
have sufficiently large cluster sizes (i.e. an average of
about 50 women per community) so as to facilitate the
estimation of community-level effects.
Household interviews were conducted in 4792 households and individual interviews were administered to 2872
women ages 18–35. The EGSF fieldwork was carried out
between May and October 1995. The individual interview
included a calendar for collecting detailed information
about diarrheal and respiratory illnesses experienced by a
woman’s two youngest children (children born since
January 1990) during the 2 weeks prior to the interview
(Goldman, Vaughan & Pebley, 1998). This section of the
questionnaire also asked women about why their child
became ill if diarrheal or respiratory symptoms were
reported. A separate section of the questionnaire
obtained information on beliefs about illness and on
beliefs related to health care providers. The questionnaire
In the analysis, we examine two measures of beliefs
about diarrhea causation. The first measure is based on
responses to a hypothetical question about the causes of
a diarrheal illness. Interviewers read a short hypothetical
vignette about a 2-year old child who had diarrhea
several times a day for the last 5 days and asked the
respondent why she thought the child had become ill.5
The second measure is derived from women who
reported that at least one of their own children had
diarrhea during the preceding 2 weeks6 and is based on
their responses to a question about what caused this
actual episode of illness. Using results from our earlier
work with in-depth interviews on diarrheal illness in
rural communities of Guatemala (Pebley et al., 1999), we
classified responses to these two questions into the
categories shown in Table 1. The first column of the
table shows responses to the hypothetical question for
the full sample of women. The remaining two columns
show responses to the hypothetical question and to the
question about their own child’s illness for the sample of
mothers whose children had an episode of diarrhea
during the preceding 2 weeks.7
4
Public use EGSF files and documentation are available from
http://www.rand.org/organization/drd/labor/FLS.
5
The specific question was ‘‘Un niño de dos años tiene
asientos de color amarillo. En los últimos 5 días ha tenido
asientos varias veces al dia. ¿Por qué cree usted que el niño se
enfermó?’’ or ‘‘A two-year old child has diarrhea that is yellow
in color. In the last 5 days he has had diarrhea (loose stools)
several times a day. Why do you think the child got sick?’’
There were 20 precoded responses (including don’t know) as well
as a write-in option for other answers.
6
Women were asked about the prevalence during the past 2
weeks of eight specific symptoms related to acute respiratory
infection and diarrhea. For this analysis, we include only those
children for whom the mother reported that the child
experienced at least three stools a day of diarrhea during this
2-week period. For any child that experienced at least one of the
eight specified symptoms, mothers were asked: ‘‘¿Por qué dice o
por qué cree usted que se enfermó (NAME OF CHILD)?’’ or
‘‘Why do you think that (NAME OF CHILD) got sick?’’ The
response categories were identical to those for the hypothetical
vignette.
7
In order to make the sample based on actual illness
comparable to the woman-based sample for the hypothetical
scenario, one child was randomly selected in the cases where a
mother had two children with recent diarrheal illness.
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N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
Table 1
Percent of respondents with various beliefs about causes of diarrhea, for hypothetical scenario and for own child with diarrhea, EGSF,
1995a
Belief about causes of diarrhea
Hygiene/contamination
Hygienec
Contaminationd
Eatinge
Inadequate caref
Chilled, cold/wet, rainyg
Weather/seasonh
Heat/suni
Classic folk illnessesj
Specific illness termsk
Wormsl
Developmental stagesm
Othern
Don’t know
Number of respondents
Hypothetical scenario
Child with diarrhea
b
Full sample
Reduced sample
31.1
23.8
9.1
26.3
23.5
5.2
2.0
4.9
7.5
0.7
6.9
0.9
1.0
24.1
2827
28.2
21.1
7.9
25.0
17.7
7.7
3.3
8.5
9.7
1.0
7.9
1.0
1.0
23.7
611
11.0
6.0
5.7
20.0
10.1
15.4
8.9
7.0
8.9
2.4
8.0
3.3
5.8
22.9
616
a
Entries sum to more than 100% because of multiple responses. Similarly, entries for the categories ‘‘Hygiene’’ and
‘‘Contamination’’ sum to more than the category ‘‘Hygiene/contamination’’. Samples sizes for the last two columns differ slightly
because of missing values.
b
The reduced sample consists of mothers whose children had an episode of diarrhea during the preceding 2 weeks.
c
The most common responses are: eating dirty or contaminated things/earth, dirty hands, lack of hygiene, contaminated/not boiled/
dirty water.
d
The most common responses are: infection, microbes, amoebas, parasites.
e
The most common responses are: eating too much/too much fruit/something that made him/her sick, malnutrition/lack of food,
wrong feeding times. This category includes eating foods believed to be ‘‘cold’’.
f
The Spanish term is ‘‘descuido’’.
g
The most common responses are: too much cold, rainy/rainy season.
h
The most common response is: season of illnesses.
i
The most common response is: too much heat. This category includes eating foods believed to be ‘‘hot’’.
j
The most common responses are: empacho, evil eye/evil spirit and susto.
k
The most common response is: cough.
l
The Spanish term is ‘‘lombrices’’.
m
The most common response is: teething.
The estimates in Table 1 indicate that, for both the
hypothetical and the actual case of diarrhea, about onequarter of women were unable to answer the question
about the cause of illness. The remaining women
supplied between one and four causes each, with an
average of about 1.6 causes per woman for the
hypothetical illness and 1.5 for the actual illness
(estimates not shown).
As shown in Table 1, almost one third of the sample
gave responses to the hypothetical question that appear
to be consistent with the germ theory of disease. We
have subdivided these responses into two related
subgroups: (1) hygiene, and (2) ‘‘contamination’’ (a
label that we use in this paper to refer to explanations
involving pathogens). As the footnotes in Table 1
indicate, the first group includes responses such as
eating dirty things or putting them into the mouth, not
washing hands, and lack of hygiene. The second group
includes words or phrases that would appear to be more
directly related to biomedical ideas about disease
transmission, e.g. infection, microbes, amoebas, and
parasites. Overall, about three-quarters of responses in
the combined category pertain to hygiene-related
explanations. It is important to note that the division
of responses into these two subgroups is somewhat
arbitrary. In particular, while some of the responses that
we label as contamination may reflect a more sophisticated understanding of the process of disease transmission, others probably do not. For example, McKee
(1987, p. 1148) reports that in Ecuador, mothers’ use of
the word ‘‘infección’’ in connection with diarrheal illness
represents ‘‘a partial accommodation to modern medical
58
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
therapies’’ which is not necessarily accompanied by
‘‘true acceptance of the germ theory of disease’’.
Other prominent causes shown in Table 1 include
improper eating and inadequate care for children, each
of which is offered by about one-quarter of women in
the total sample. Alternative beliefs about illness
causation that are commonly discussed in the medical
anthropological literature on Guatemala, such as hotcold imbalance, worms, and classic folk illnesses (susto,
empacho, evil eye) are less common in our sample.
Elsewhere we have argued that there may be a decline in
belief in these more traditional causes of diarrhea in
rural Guatemala (Pebley et al., 1999).
Responses to the hypothetical question are quite
similar for the entire sample and for the subsample of
women whose child had a recent episode of diarrhea.
However, a comparison of the second and third columns
shows that the subsample of women whose child had a
recent episode of diarrhea gave substantially different
responses to the hypothetical question and to the
question about the causes of their own child’s diarrhea.
Specifically, these respondents were much less likely to
give hygiene or contamination-related responses for
their own child than for the hypothetical one. Part of the
difference may be due to incompatibilities between the
two questions. For example, since mothers were asked
about the cause of the entire illness episode } which
may have included non-diarrheal symptoms } responses to the actual illness episode may include
mothers’ perceptions related to these other symptoms.
In contrast, the hypothetical question referred only to
diarrhea, specifically diarrhea that was yellow in color.
Previous anthropological literature suggests that rural
Guatemalan women distinguish among different types of
diarrhea partly by its color (Burleigh, Dandano & Cruz,
1990). However, the differences in responses may also
reflect a reluctance on the part of mothers to acknowledge poor hygiene in their own homes even though they
recognize it as a cause of diarrhea for others. Alternatively, mothers may be more likely to give what is
perceived as a socially-accepted response (e.g. hygiene)
to a simple hypothetical question but a more idiosyncratic response when they know more about the
circumstances of the illness (e.g. what the child ate that
day, whether the child was exposed to extremes in
temperature, and whether the child gets sick frequently).
The outcome measures that form the basis for this
analysis focus specifically on whether or not women
provided responses to questions about the causes of
diarrhea that are related to hygiene or contamination. In
addition to exploring these measures of hygiene-related
beliefs, we also examine one measure of household
hygiene in the analysis: the degree of fecal or other
sources of contamination (e.g. garbage) around the
dwelling, as observed by the interviewer. Approximately
11% of dwellings were classified as having ‘‘a lot’’ of
contamination, 60% as having ‘‘some’’, and 28% as
having ‘‘none’’.
Explanatory variables
Table 2 shows the means and distributions of the
independent variables in this analysis. Three sets of
variables are employed to measure social contacts for
individual women. Measures of interpersonal contacts
outside the community include whether the respondent
reports that one or more relatives live in Guatemala City
or abroad (generally in the US or Mexico), and whether
the respondent herself ever lived in a city, large town, or
plantation (for at least a year). Both having a relative
living abroad or in Guatemala City and having lived in a
large town or city oneself are hypothesized to increase a
respondent’s likelihood of encountering hygiene-related
beliefs and norms about hygiene. Interpersonal ties
within the community include whether the respondent or
members of her family are involved in community
organizations and the frequency of the respondent’s
interaction with parents and parents-in-law. As described above, we hypothesize that women whose
families are involved (or who are involved themselves)
in the community are more likely to come into contact
with innovative ideas than women who are more socially
isolated.8 On the other hand, we hypothesize that
parents and parents-in-law may exert pressure against
adopting new ideas and behavior. For example, they
may believe that the childrearing methods that they
themselves used are most appropriate and that changes
may endanger their own authority or the well-being of
their grandchildren. Therefore, respondents who live
with or near parents or in-laws or who see them
frequently may be less likely to adopt hygiene-related
beliefs.
One type of impersonal contact, the use of mass
media, is represented by a variable indicating whether or
not the respondent watches TV or listens to the radio
frequently (at least once a week). Note that, unlike
earlier work on the effect on contraceptive use of family
planning-related messages broadcast through TV and
radio (Bankole et al., 1996), we are not examining the
specific content of the radio or TV programs that
respondents listened to or viewed. Explicit health
messages are relatively uncommon in Guatemalan mass
media. Rather, we hypothesize that general program8
The variable measuring community involvement is based on
three questions: (1) whether the respondent or a relative was a
member of a committee in the community, a cooperative or
some other organization during the past five years; (2) whether
the respondent or a relative held a directive position in a
religious organization or a political position during the past five
years; and (3) whether the respondent was in a cooperative, or
women’s group at the time of the survey.
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N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
Table 2
Distribution of explanatory variables
Characteristics of respondent/household
Personal ties outside community
% with relative abroad or in Guatemala City
% ever lived in a large place
Personal ties in community
% involved in community groups
Contact with parents/in-laws (%)
Coreside/live next door
See at least one parent/in-law weekly
See less often or not alive
Impersonal contacts
% using TV/radio frequently
Social, economic and demographic characteristics
Woman’s education (years)
Consumption index (quetzales/person/month)
Perceived relative poverty (%)
Same or better
Much poorer
Missing
Woman’s age (years)
Woman’s ethnicity/language (%)
Ladino
Indigenous, Spanish
Indigenous, no Spanish
Parity (%)
0
1–2
3
Sample size
Mean or %
54.3
9.6
32.8
46.6
42.3
11.1
83.6
2.8
25.2
68.0
30.8
1.2
25.8
Characteristics of community
Ties outside community
% with frequent migration abroad
% with frequent migration to plantations
% with bus service and road open in past year
Outside programs
Water committee (%)
No piped water, no committee
Piped water, no committee
Water committee
Mean or %
23.3
31.7
46.7
26.7
63.3
10.0
Size and remoteness
Community size (%)
52500 persons
52500 persons
Missing
41.7
55.0
3.3
Distance to Guatemala City (km)
79.9
Sample size
60
35.5
52.9
11.6
23.0
28.0
49.0
2792
ming provides (albeit unintentionally) informational and
normative content about the importance of cleanliness
and connects hygienic-behavior with middle class values
and upward mobility. Overall, about three-quarters of
respondents are frequent listeners of the radio and about
one-third are frequent viewers of television.
The analysis also includes a series of individual-level
social, economic, and demographic variables which are
hypothesized to affect the probability that an individual
adopts hygiene-related beliefs. As is apparent from
Table 2, mean levels of educational attainment for
women in the communities in our sample are low.
Nonetheless, previous research suggests that even a few
years of education are likely to increase the likelihood
that women adopt hygiene-related beliefs for several
reasons (Caldwell, 1986; Cleland, 1990; Lindenbaum,
1990, Das Gupta, 1990). First, schools generally
emphasize neatness and order even if they do not
teach hygiene explicitly. Education can also provide the
means for translating new ideas into action by promoting new ways of thinking and increasing self-esteem.
Furthermore, women who have been to school in rural
Guatemala may identify themselves more closely with
urban, ‘‘modern’’ Guatemalan culture that includes
norms about sanitation and biomedical explanations of
disease causation.
Ethnicity may also affect the likelihood of adopting
innovative health beliefs in several, sometimes counteracting, ways. Indigenous women who do not speak
Spanish are more isolated from the influence of
principally ladino, and entirely Spanish-speaking,
urban Guatemalan society. More generally, because
of 500 years of resistance against assimilation
(‘‘ladinoization’’), there have been strong norms in some
indigenous communities against the adoption of ideas,
beliefs, and behavior which are believed to be ‘‘ladino’’.
Recent changes in Guatemala, including the end of a 30
year old civil war, have lead to many changes in
indigenous communities which were underway at the
time of the EGSF. These changes include the growth of
an indigenous identity movement that may foster the
retention of traditional beliefs about illness. On the
other hand, improved economic opportunities and
increased contact between rural communities and the
60
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
urban environment of Guatemala City may mean that
indigenous families are more likely to adopt hygienerelated beliefs and better able to implement them
because of somewhat better standards of living than
they were in the past.9
Economic status may affect women’s responses about
the causes of diarrheal illness for several reasons. For
example, poorer women may feel they have little choice
about the sanitation of the environment they live in and
may be more comfortable giving responses related to
factors which are under their control. Women in higher
income families are also likely to be exposed to hygienerelated ideas and to experience normative pressure to
implement hygienic practices by friends and family.
Economic status is also likely to have a major effect on
the level of contamination observed in and around the
dwelling. Income is particularly difficult to measure in
rural areas, where considerable income continues to
be earned through subsistence agriculture, and cash
income is obtained through a wide variety of often
short-term (e.g. 3-day or 2-week long) jobs. Instead of
measuring income directly, we use a measure of
consumption } average monthly household consumption per capita } that was developed from answers to a
detailed household consumption history about expenditures in the week and the month preceding the survey
(see Peterson, Goldman & Pebley, 1997, for details).
We also include a measure of perceived relative
income, based on a question about whether the
respondent believes her household is better off, about
the same, or worse off than others in the community.
Our hypothesis is that, in the presence of controls for the
level of consumption, respondents who believe that they
are poorer than the typical household are less likely to
adopt hygiene-related beliefs and behavior because they
are less apt to identify with middle-class urban
Guatemalan culture.
Two other individual level variables in the analysis are
maternal age and parity, which are included as measures
of overall experience and experience with children.
While older women may be slower to adopt new ideas
and behavior, the women in our sample are all fairly
young (18–35 years olds). We hypothesize that women
with more life experience may have more self-confidence
as well as more exposure to innovative ideas, and may
thus be more likely to adopt new ideas and behaviors.
Similarly, women who have already had a child or
several children may have greater exposure to ideas
about the rearing of children and about preventing and
treating child illness.
9
Despite some improvement in standard of living, it is
important to note that the indigenous population remains
considerably poorer on average than other Guatemalans
(Psacharopoulos & Patrinos, 1994) and continues to face overt
discrimination in many parts of society.
The right side of Table 2 lists community-level
variables included in the analysis, based largely on
information collected in the interviews with key informants. Above we described one measure of impersonal contact, namely exposure to mass media. A second
type of impersonal contact relates to public health or
public works programs. The EGSF collected data on all
types of non-governmental organizations (NGOs) and
governmental programs which were active in each
community. Our earlier qualitative field work (Pebley
et al., 1999) suggested that water programs were
particularly effective as conduits for hygiene-related
ideas. Water programs in rural Guatemala typically help
communities organize themselves to identify sources of
clean water and to design and install a system for
delivering the water to the community. Because the
labor and some of the materials involved must be
donated by the community, water committees spend
considerable effort in each community on education
about the importance of clean water and sanitation. We
have, therefore, included a variable which indicates
whether the community already has piped water or
whether there was an active water committee at the time
of the survey.10
The other community-level variables are measures of
the degree of contact that each community has with
urban Guatemalan society and with the rest of the world
outside of Guatemala. Each of these variables was
derived by taking median values of responses given by
the three key informants in the community. We include
two variables related to migration. The first identifies
communities that experience frequent international
migration and the second identifies communities with
frequent migration to agricultural plantations, generally
on the Atlantic or Pacific Coasts; ‘‘frequent’’ migration
reflects responses that indicate that migration is either
‘‘common’’ or ‘‘very common’’ in the community.
Seasonal agricultural migration has been commonplace
for many years, especially for people living in areas where
agricultural land is scarce. Plantations bring together
both indigenous and ladino Guatemalans from all parts
of the country for a few months at a time and may serve
as pathways for diffusion of ideas. Bus service,11 distance
10
We also examined the effects of health and nutrition
programs run by governmental and non-governmental organizations, but found that they were unrelated to our outcome
variables. They are, therefore, not included in the analysis
presented here. In addition, we explored including several
additional explanatory variables } religion and movement of
persons in and out of the household during the past year } but
these variables had no association with our outcome measures
and were subsequently dropped from the models.
11
This variable denotes the presence of regular bus service in
communities for which the principal road was open for 12
months during the past year.
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
to Guatemala City,12 and the size of the community
reflect the degree of isolation from or integration with
urban Guatemalan society.
We have not included in our analysis any variables
related to the respondent’s experience with health
providers or the existence of different types of health
providers in or near the community. While it is possible
that some health providers impart information related
to the importance of hygiene in preventing illness, we
suspect that most providers offer their patients little
information on such issues. Moreover, it is very likely
that a family’s set of health beliefs affects its use of
different types of providers (e.g. traditional curers versus
biomedical practitioners), so that it would be virtually
impossible to disentangle the direction of the association
between beliefs and the use of health services in a crosssectional analysis.
Results
Beliefs about diarrheal illness
In Tables 3 and 4 we present estimates from binomial
and multinomial logit models of the probability that
women report causes of diarrhea related to hygiene or
contamination. The estimates in Table 3 are based on
the full sample } 2792 women with complete information on all variables of interest } and are derived from
(1) a binomial logit model in which hygiene and
contamination beliefs are combined into a single outcome; and (2) a multinomial logit model with separate
outcomes for hygiene-related and for contaminationrelated beliefs. The estimates in Table 4 are based on
(binomial) logit models (hygiene and contamination
beliefs combined) for the subsample of about 600
mothers whose children experienced a recent episode
of diarrhea. Both sets of models include the explanatory
variables described above and shown in Table 2. In
addition, these models include a set of dummy variables
representing the four departments in which the survey
took place. The inclusion of these dummy variables
compensates for the sampling design of the EGSF (i.e.
the sample was stratified by department) and also
12
We do not have data on the distance or the travel time from
the community itself to Guatemala City. Instead we have used
information on the distance between the municipal capital and
Guatemala City.
13
In the case of the multinomial logit models, the term
relative probability ratio (or relative risk ratio) may be
preferable to odds ratio since a non-dichotomous outcome
implies that the respective probabilities (e.g. the probability of
having hygiene-related beliefs vs the probability of having
neither hygiene nor contamination-related beliefs) no longer
sum to unity.
61
captures variation across departments that is not
measured by other variables in the model. The values
presented in the tables are exponentiated parameter
estimates, which can be interpreted as odds ratios.13
The estimates in the first two columns of Table 3
support some, but not all, of our hypotheses. Two of the
variables measuring interpersonal ties appear to be
important determinants of hygiene/contamination-related beliefs, namely whether the respondent has
relatives abroad or in the capital and whether the
respondent or a family member is active in a community
organization. Each of these variables is associated with
an increase in the odds of about 25% (relative to the
respective omitted category). The remaining social
contact variables have insignificant effects.
The estimated effects for social, economic and
demographic characteristics are typically larger than
those for the contact variables and all are statistically
significant. For example, the number of years of
education of the woman and the household’s economic
status, as measured both by actual consumption levels
and by self-assessed relative status, are strongly and
positively associated with the likelihood of holding
beliefs related to hygiene or contamination. The effects
of ethnicity imply that use of Spanish is more important
than other aspects of ethnic identification: indigenous
Spanish speaking women are about as likely to have
hygiene/contamination-related beliefs as ladinos, but
indigenous women speaking only Mayan languages are
much less likely to do so. The effects of parity suggest
that having several children substantially increases the
likelihood of having beliefs related to hygiene or
contamination, while the effects of age indicate that
the older the respondent the more likely she is to have
such beliefs.
The estimates for the community-level variables in the
logit model only partly support our hypotheses. Women
living in communities with larger population sizes and
closer proximity to the capital are significantly more
likely to hold hygiene/contamination-related beliefs than
their respective counterparts. However, contrary to our
hypotheses, the variables denoting frequent international migration, frequent migration to plantations, the
presence of a water committee and piped water, and
regular bus service are not significantly associated with
hygiene/contamination-related beliefs.
Estimates in the remaining columns of Table 3 are
based on a multinomial logit model in which responses
related to hygiene (such as eating dirty things or unclean
food or water) are distinguished from responses related
to contamination (such as infection or specific pathogens), and are compared with all other types of
responses. The resulting estimates reveal several very
strong associations between contamination-related beliefs
and explanatory variables related to social contacts and
individual, household and community characteristics. In
62
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
Table 3
Estimated odds ratios and t-values for binomial and multinomial logit models of the probability of holding beliefs related to hygiene
and/or contamination, based on full sample of women
Covariatesa
Contacts
(No relative abroad or in Guatemala City)
Relative abroad or in Guatemala City
(Never lived in large place)
Ever lived in large place
(Resp. and relative not in community group)
Involved in community group
(Parents or in-laws coreside/next door)
See at least one weekly
See less often or not alive
(Not using TV/radio frequently)
Use TV/radio frequently
Social, economic and demographic characteristics
Woman’s education (years)
(Consumption index below median)
Consumption index 50–90%
Consumption index >90%
(Household same or better economically)b
Household much poorer
Woman’s age (years)
(Woman ladino)
Woman indigenous, Spanish
Woman indigenous, no Spanish
(Parity 0)
Parity 1–2
Parity 3
Community characteristics
(No/infrequent migration abroad)
Frequent migration abroad
(No/infrequent migration to plantations)
Frequent migration to plantations
(No bus service or road closed)
Bus service and road open
(No piped water, no committee)
Piped water, no committee
Water committee
(52500 persons)b
2500 persons
Distance to Guatemala City (km.)
(Chimaltenango)
Totonicapán
Suchitepequez
Jalapa
Pseudo R2z
Number of respondents
Binomial logit
Multinomial logit
Hygiene or contamination
Hygiene
Odds ratio
t-value
Odds ratio
t-value
1.24
2.23
1.10
0.87
1.77
3.41
1.19
1.19
1.12
0.70
1.33
1.34
1.25
2.41
1.13
1.17
1.60
3.26
0.96
1.16
ÿ0.37
1.01
0.88
1.06
ÿ1.07
0.36
1.24
1.48
1.20
1.66
1.12
0.89
1.12
0.81
1.11
0.45
1.11
y
1.20
1.47
6.30
5.19
0.67
1.86
1.13
y
1.63
1.78
4.80
1.93
2.48
1.10
y
1.07
1.38
ÿ2.11
3.42
0.78
1.02
ÿ2.21
2.07
0.91
1.07
ÿ0.59
3.78
ÿ0.45
ÿ2.21
0.96
0.55
ÿ0.24
ÿ2.27
0.89
0.78
ÿ0.51
ÿ0.60
1.32
2.72
1.23
1.67
1.39
2.99
1.08
1.17
0.35
0.62
1.17
1.43
1.17
1.27
1.17
0.86
0.88
ÿ0.98
0.86
ÿ1.01
0.92
ÿ0.42
1.10
1.00
1.08
0.75
1.16
0.93
0.89
0.98
ÿ0.94
ÿ0.10
0.89
1.06
ÿ0.85
0.30
0.89
0.65
ÿ0.55
ÿ1.18
2.40
ÿ2.88
1.28
0.98
y
4.19
3.92
1.80
1.47
ÿ3.31
0.81
1.04
y
0.93
0.60
y
1.19
1.51
1.30
0.98
y
4.56
2.43
1.35
0.066
2792
2.63
ÿ3.81
5.16
3.13
1.45
1.31
0.99
y
4.41
2.00
1.19
0.067
2792
Contaminationc
4.46
2.14
0.74
Odds ratio
t-value
3.04
2.41
3.04
3.09
1.91
a
Omitted variables are indicated in parentheses. p50.05 based on t-test; yp50.05 based on chi-square test for the set of dummy
variables which comprise this covariate. For the multinomial logit model, the test is based on variables for both outcomes; z percent
reduction in deviance from the null model.
b
These variables have an additional category (not shown) for the relatively few respondents with missing information.
c
This category includes several respondents who provided both hygiene and contamination-related responses.
63
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
Table 4
Estimated odds ratios and t-values for logit models of the probability of holding beliefs related to hygiene or contamination, based on
sample of mothers whose children have diarrhea
Covariatesa
Hypothetical scenario
Odds ratio
Contacts
(No relative abroad or in Guatemala City)
Relative abroad or in Guatemala City
(Never lived in large place)
Ever lived in large place
(Resp. and relative not in community group)
Involved in community group
(Parents or in-laws coreside/next door)
See at least one weekly
See less often or not alive
(Not using TV/radio frequently)
Use TV/radio frequently
Social, economic and demographic characteristics
Woman’s education (years)
(Consumption index below median)
Consumption index 50–90%
Consumption index >90%
(Household same or better economically)b
Household much poorer
Woman’s age (years)
(Woman ladino)
Woman indigenous, Spanish
Woman indigenous, no Spanish
(Parity 1–2)
Parity 3
Community characteristics
(No/infrequent migration abroad)
Frequent migration abroad
(No/infrequent migration to plantations)
Frequent migration to plantations
(No bus service or road closed)
Bus service and road open
(No piped water, no committee)
Piped water, no committee
Water committee
(52500 persons)b
2500 persons
Distance to Guatemala City (km.)
(Chimaltenango)
Totonicapán
Suchitepequez
Jalapa
Pseudo R2z
Number of respondents
Child with diarrhea
t-value
Odds ratio
t-value
1.05
0.23
1.78
1.90
1.39
1.11
0.63
ÿ0.90
0.88
ÿ0.62
1.73
1.89
0.81
1.33
ÿ0.91
0.88
1.02
0.55
0.07
ÿ1.09
0.86
ÿ0.58
0.67
ÿ1.13
1.11
2.45
1.06
0.87
1.47
2.23
1.80
1.87
0.85
1.37
ÿ0.51
0.54
0.71
1.01
ÿ1.57
0.45
1.00
1.01
ÿ0.02
0.34
0.70
0.40
ÿ0.84
ÿ1.59
0.99
1.94
ÿ0.02
0.84
1.64
1.81
0.98
ÿ0.04
0.87
ÿ0.52
1.06
0.16
0.87
ÿ0.49
1.19
0.39
3.29
1.10
0.29
ÿ2.04
ÿ0.10
0.66
0.90
ÿ0.94
ÿ0.18
0.77
ÿ4.10
0.80
0.97
ÿ0.64
ÿ1.89
2.10
y
0.55
0.96
1.21
0.96
y
19.19
10.75
1.39
0.088
605
4.23
3.58
0.66
10.16
6.84
1.04
0.062
599
2.19
1.93
0.06
Omitted variables are indicated in parentheses. p50.05 based on t-test. yp50.05 based on chi-square test for the set of dummy
variables which comprise this covariate. z Percent reduction in deviance from the null model.
b
These variables have an additional category (not shown) for the relatively few respondents with missing information.
a
particular, women with relatives abroad or in the
capital, women who have relatives or are themselves
involved in community organizations, and women
living in households above the average level of
consumption are all much more likely to have beliefs
related to contamination than their respective counter-
64
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
Table 5
Estimated odds ratios and t-values for logit model of the probability that the respondent’s dwelling is uncontaminated
Covariatesa
Contacts
(No relative abroad or in Guatemala City)
Relative abroad or in Guatemala City
(Never lived in large place)
Ever lived in large place
(Resp. and relative not in community group)
Involved in community group
(Parents or in-laws coreside/next door)
See at least one weekly
See less often or not alive
(Not using TV/radio frequently)
Use TV/radio frequently
Social, economic and demographic characteristics
Woman’s education (years)
(Consumption index below median)
Consumption index 50–90%
Consumption index >90%
(Household same or better economically)b
Household much poorer
Woman’s age (years)
(Woman ladino)
Woman indigenous, Spanish
Woman indigenous, no Spanish
(Parity 0)
Parity 1–2
Parity 53
Community characteristics
(No/infrequent migration abroad)
Frequent migration abroad
(No/infrequent migration to plantations)
Frequent migration to plantations
(No bus service or road closed)
Bus service and road open
(No piped water, no committee)
Piped water, no committee
Water committee
(52500 persons)b
52500 persons
Distance to Guatemala City (km)
(Chimaltenango)
Totonicapán
Suchitepequez
Jalapa
Pseudo R2z
Number of respondents
Odds
ratio
t-value
1.44
3.48
1.04
0.24
0.98
ÿ0.24
1.06
0.98
0.49
ÿ0.10
0.89
ÿ0.87
1.13
y
1.30
2.09
6.68
0.65
1.03
y
0.64
0.37
y
0.68
0.50
ÿ3.90
2.59
2.52
4.57
ÿ2.60
ÿ3.78
ÿ2.92
ÿ4.25
1.00
0.03
0.90
ÿ0.73
1.34
1.22
1.00
1.49
0.99
y
14.36
13.68
4.97
0.158
2782
2.74
1.48
ÿ0.01
3.54
ÿ3.05
8.08
8.41
6.96
a
Omitted variables are indicated in parentheses. p50.05 based on t-test; yp50.05 based on chi-square test for the set of dummy
variables which comprise this covariate; z Percent reduction in deviance from the null model.
b
These variables have an additional category (not shown) for the relatively few respondents with missing information.
parts. In each of these cases, the odds ratio is at least as
large as 1.6 and is considerably larger than the
corresponding odds ratio associated with hygiene-related
beliefs.
These differences indicate that interpersonal social
contacts outside and within the community significantly
increase the likelihood of a contamination-related
response } i.e. a response expressed in ostensibly
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
biomedical terms } but not a hygiene-related response.
It appears that women who give contamination
responses are a more highly select group in terms of
social contacts and socioeconomic status than those who
give explanations related to hygiene.
The estimates in Table 4 are based on the same
(binomial) logit model14 as in the first two columns of
Table 3, but are derived from the subsample of
women whose children experienced diarrheal illness
within the two-week period prior to the survey. The
first two columns of Table 4 pertain to responses for
the hypothetical vignette whereas the last two columns
pertain to mothers’ perceived causes of illness for
actual diarrheal episodes among their children. Earlier
(Table 1) we saw that women provided very different
answers to these two sets of questions, with mothers
being much less likely to give hygiene or contamination
responses for their own child as compared with the
hypothetical one. Tabulations not presented here
indicate that less than one-fifth of mothers who gave
hygiene/contamination-related answers for the hypothetical vignette did so for their own children with diarrheal
illness.
A comparison of the two sets of estimates in Table 4
suggests further that the types of women who are most
likely to give hygiene or contamination-related answers
differs between these two settings. In the hypothetical
scenario, the most important correlates describe socioeconomic status or community characteristics, whereas
for women’s own children, two measures of interpersonal contacts (having a relative abroad or in Guatemala
City, and involvement in a community group) appear to
be more important than the other variables (although
not significant at the 5% level).
Observed levels of household contamination
In contrast to our previous focus on beliefs, below we
consider the extent to which respondents use hygienic
practices. We focus on one aspect of hygiene measured
in the EGSF, namely the absence of fecal or other types
of contamination (such as garbage) around the dwelling.
Although interviewers assessed the degree of contamination in three categories (none, some, and a lot), we
consider the dichotomous outcome of whether or not
the household is considered uncontaminated (i.e. clean).
Overall, 28% of the households in this analysis were
assessed as being uncontaminated.
How likely are those respondents who report hygiene
or contamination-related beliefs to maintain clean
14
The dummy variable denoting parity 0 has been dropped
from the models in Table 4 because this subsample is restricted
to women who have at least one child. We have chosen to
combine responses related to hygiene and contamination
because of the relatively small sample sizes in Table 4.
65
households themselves? A simple tabulation (not shown)
indicates that the correlation between hygienerelated beliefs and behavior is modest: about 35% of
women who give hygiene or contamination-related
responses regarding diarrhea causation have clean
households, in contrast to 25% of women who offer
different responses.
The model in Table 5 explores the determinants of
household cleanliness, based on a logit model. Results
from ordered logit and multinomial logit models (that
use three categories of assessed cleanliness) are similar to
those shown in Table 5. The estimates indicate that
many of the same variables that are associated with
beliefs about hygiene are also associated with hygienic
behavior. In several cases, the odds ratios are larger in
Table 5 than in Table 3, suggesting that the differentials
are even more important with regard to actual behavior.
While this finding supports our hypothesis that the
diffusion process involves norms about hygienic behavior as well as information about hygiene, the results
indicate that only one of the interpersonal contact
variables (having relatives abroad or in Guatemala City)
has an important association with observed cleanliness.
On the other hand, cleanliness appears to be more
prevalent in communities with regular bus service, in
larger areas and in areas closer to Guatemala City,
possibly as a result of social ties with urban Guatemalan
society.
There are several noteworthy differences between the
estimates presented in Table 5 and those shown in Table
3 for hygiene/contamination-related beliefs. First, the
nature of the association between parity and cleanliness
is reversed from that found for beliefs. This result is not
surprising since it is much more difficult to avoid fecal
contamination and the presence of garbage when
young children are around. Second, the presence of
regular bus service is significantly associated with
cleanliness but not with beliefs. Third, participation in
a community group is significantly associated with
beliefs but not with cleanliness. An additional unexpected result is the large values of the odds ratios for the
departmental variables, particularly in light of the
finding that the highest levels of cleanliness are
associated with the poorest department (Totonicapán).
We speculate that much of this departmental-level
variation is the result of employing different interviewer
teams in each department, typically using team members
who normally resided in their assigned department.
Interview teams in the poorest areas may have been
reluctant to acknowledge the lack of cleanliness or may
have different standards than the other teams for
assessing the level of hygiene. On the other hand, the
fact that the estimates by department in Table 5 reflect
the same ordering as those in Table 3 suggests that s
ome of the department-level effects may reflect actual
variation in knowledge and behavior related to
66
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
hygiene that is not captured by the covariates in the
model.
Community-level effects
A simple tabulation reveals that the overall proportion of women giving responses related to hygiene or
contamination (to the hypothetical vignette question)
varies considerably across the 60 communities in the
analysis: two communities have values as low as 10%,
while five communities have values over 50% (with a
maximum of 63%). This variation suggests that there
may be important community-level effects related to
health beliefs } effects that may not be captured fully by
the explanatory variables in Table 2. In an effort to
ascertain the degree to which hygiene/contaminationrelated beliefs are homogeneous within communities, as
well as to correct the logit models presented above
for potential bias in the estimated coefficients and standard errors resulting from failure to account for
such clustering (see, for example, Rodriguez &
Goldman 1995), we estimated multilevel logit models
corresponding to the ordinary logit models presented
above.
The two-level logit model can be expressed in terms of
pij, the probability that the jth women in the ith
community has hygiene/contamination-related beliefs,
and zi, unobserved characteristics of community i:
logit pij ¼ b0 xij þ szi :
ð1Þ
If we ignore the last term on the right-hand side of Eq.
(1), we have the ordinary logit model in which b is a
vector of regression coefficients corresponding to the
effects of fixed covariates xij (i.e. the observed characteristics of the community and the respondent shown
in Table 2). The last term captures the unobserved
effects of the community, with s representing the
regression coefficient corresponding to the random effect
zi. Thus, for example, a value of zero for s indicates that
there is no variation across communities and that the
two-level logit model can be reduced to the ordinary
logit model.
In the conventional formulation, the random effects zi
are assumed to have a standard normal distribution.
However, in this analysis we assume instead that the zi
have a standardized binomial distribution (or, equivalently, we employ a binomial approximation to the
normal distribution) so that we can fit the logisticbinomial model included in the statistical package
EGRET (Statistics and Epidemiology Research Corporation 1985–1993). The models are estimated via
maximum likelihood procedures.
The table in Appendix A presents the estimated odds
ratios, s, and t-statistics for the two-level equivalent of
the logit model shown in Table 3. A comparison
between the estimates in the first two columns of
Table 3 and those in Appendix A reveals that the two
sets of coefficients (or odds ratios) are almost identical.
Thus, failure to account for community-level clustering
in this case results in a trivial bias for the coefficients of
the observed explanatory variables. In addition, the tvalues reveal that failure to account for clustering results
in a very modest underestimate of the standard
errors for community-level coefficients and virtually
no underestimate for individual or household-level
variables. The results also demonstrate that although
the community-level effect is significantly greater
than zero (the estimated s equals 0.24), it is very
modest, especially compared with the extremely large
community-level effects estimated for health care
behaviors (such as pregnancy-related care and immunization) in Guatemala (Pebley, Goldman, & Rodriguez
1996).
Since the estimates for the ordinary logit and multilevel logit models for hygiene/contamination-related
beliefs in the full sample are so similar, we do not
present additional multilevel estimates here. However, it
is interesting to consider the magnitude of the estimated
community-level random effects for the multilevel
extension of the models in Table 4 } i.e. the models
based on the subsample of mothers whose children had a
recent episode of diarrhea. These estimates of s are 0.30
(p=0.21) for the hypothetical child and 0.20 10ÿ15
(p=0.50) for the actual child. Thus, in the subsample of
mothers, there is a modest (but not significant) level of
clustering within communities of hygiene/contamination-related beliefs for the hypothetical child but
absolutely no clustering within communities for beliefs
related to one’s own children. This finding further
supports our contention that the assessment of cause of
illness for a woman’s own child depends on numerous
factors external to any diffusion process related to the
germ theory of disease. It is also interesting to note that
the estimated s for the multilevel logit model related to
cleanliness of the dwelling equals 0.42 (p=0.002), a value
almost twice as large as that shown in Appendix A
for hygiene/contamination-related beliefs based on
the same sample. This comparison suggests that there
may be a greater degree of clustering of hygiene-related
behaviors than of hygiene-related beliefs within
communities.
Conclusions
In this paper, we have tried to determine whether
there is evidence of the diffusion of beliefs related to
the germ theory of disease through social ties in
contemporary rural Guatemala. Following earlier
work on the diffusion of innovative fertility behavior
we hypothesized that two types of social contacts,
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
interpersonal and impersonal contacts, are important
conduits for both information and norms about hygiene
and contamination as a cause of diarrheal illness in
children.
Our results show that there is evidence of a diffusion
process through social contacts, but primarily through
interpersonal rather than impersonal contacts. The two
measures of impersonal contacts included in the
analysis, i.e. exposure to mass media and the existence
of a water committee in the community, are not
significantly related to either hygiene/contamination
beliefs or hygienic behavior. In the case of mass media,
we conclude that general programming is not an
important source of information related to norms about
cleanliness. However, given the very high proportion of
rural women who listen to radio or watch TV frequently,
mass media might be a highly effective way of
transmitting health-related information if it were to
contain specific health-related content. The lack of a
significant relationship between beliefs, behavior and
the existence of a water committee is more surprising
given our earlier observations (Pebley et al., 1999)
about the role of water committees in promoting
hygiene. The lack of significance may be due to better
controls for other community characteristics in this
analysis.
In terms of interpersonal social contacts, having a
relative living abroad or in Guatemala City appears to
be the most consistently important conduit for diffusion
of hygiene-related ideas in the sense that it is significantly and positively related both to holding hygiene/
contamination beliefs and to practicing hygienic behavior. Participation in community groups is also a
significant determinant of hygiene/contamination beliefs. Other measures of interpersonal social contacts,
however, are not statistically significant.
Variables directly measuring community (rather than
personal) ties with the outside world, such as the
frequency of migration abroad and to plantations, are
not significantly related to beliefs or behavior. However,
an indirect measure of social contact, distance to
Guatemala City, is strongly related to both beliefs and
behavior, except with regard to diarrhea among
women’s own children. Respondents in communities
which are closer to Guatemala City are more likely to
give causes related to hygiene or contamination and to
have uncontaminated households. Hygiene/contamination-related beliefs and behavior are also generally more
common in larger communities and hygienic behavior is
more apparent in communities with regular bus service.
We conclude that variables denoting distance, size, and
availability of transport are measuring aspects of social
contacts at the community level that have important
effects on the diffusion process that are not being
captured by our social contact variables at the community and individual levels.
67
Another important finding is that interpersonal social
contacts are strongly related to contaminationrelated beliefs, but not to more general hygiene-related
beliefs. Adopting the apparently more sophisticated
understanding of illness transmission associated with
the former category of responses may require considerably more contact with sources of information about
the germ theory of disease than more elementary beliefs
about the importance of hygiene. An alternative
interpretation is that individuals with more status
within their own community or more contact with the
outside world are more likely to know and use terms
(especially when speaking to outsiders) that they
associate with well educated urban Guatemalans, even
though they hold the same beliefs as their neighbors
about illness causation.
Our results also demonstrate that social and economic
characteristics are strongly associated with the likelihood of holding beliefs related to hygiene or contamination and with hygienic behavior. In particular,
women with more education and those living in households above the average level of consumption are more
likely to both have these beliefs and to live in
uncontaminated dwellings.
Finally, our findings show that the perceived causes of
illness depend on the context. Specifically, respondents
are likely to give different answers about the cause of
their own children’s illness than about a hypothetical
vignette. We speculate that there are at least two reasons
for this finding. Even those respondents who are most
likely to have been exposed to ideas about hygiene and
contamination (1) may be reluctant to acknowledge lack
of cleanliness with regard to their own households and
children; or (2) may find alternative explanations of
illness (such as those related to food, lack
of care, or weather) more convincing when they know
the details surrounding their own children’s experiences.
Acknowledgements
Support for this project from NICHD through grants
R01 HD27361 to RAND and R01 HD31327 and 5P30
HD32030 to Princeton University is gratefully acknowledged. The Guatemalan Survey of Family Health
(EGSF) was carried out in collaboration with the
Instituto de Nutrición de Centro América y Panamá
(INCAP) in Guatemala. We are grateful for the
technical and substantive contributions of INCAP
colleagues. In addition, we would like to thank Germán
Rodriguez and Michele Gragnolati for their advice and
assistance throughout the analysis. An earlier version of
this paper was presented at the Workshop on Social
Processes Underlying Fertility Change in Developing
Countries, Committee on Population, National Academy of Sciences, 29–30 January, 1998.
68
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
Appendix A. Estimated odds ratios and t-values for
multilevel logit model of the probability of holding beliefs
related to hygiene or contamination, based on full sample
of women
Covariatesa
Contacts
(No relative abroad or in Guatemala City)
Relative abroad or in Guatemala
City
(Never lived in large place)
Ever lived in large place
(Resp. and relative not in community group)
Involved in community group
(Parents or in-laws coreside/next
door)
See at least one weekly
See less often or not alive
(Not using TV/radio frequently)
Use TV/radio frequently
Social, economic and demographic
characteristics
Woman’s education (years)
(Consumption index below median)
Consumption index 50–90%
Consumption index >90%
(Household same or better economically)c
Household much poorer
Woman’s age (years)
(Woman ladino)
Woman indigenous, Spanish
Woman indigenous, no Spanish
(Parity 0)
Parity 1–2
Parity 3
Community characteristics
(No/infrequent migration
abroad)
Frequent migration abroad
(No/infrequent migration to
plantations)
Frequent migration to plantations
(No bus service or road closed)
Bus service and road open
(No piped water, no committee)
Piped water, no committee
Water committee
(52500 persons)c
2500 persons
Odds ratio t-value
1.23
2.14
1.18
1.12
1.26
2.43
0.97
1.17
ÿ0.30
1.01
1.11
0.79
1.11
5.81
1.22
1.52
2.02
2.63
0.81
1.04
ÿ2.11
3.25
0.95
0.59
ÿ0.32
ÿ2.12
1.19
1.55
1.34
2.86
1.19
1.24
0.87
ÿ0.87
1.11
0.87
0.89
0.97
ÿ0.78
ÿ0.13
1.34
2.32
Covariatesa
Odds ratio t-value
Distance to Guatemala City (km)
0.98
(Chimaltenango)
Totonicapán
4.36
Suchitepequez
2.36
Jalapa
1.35
Random effect for community
0.24
(s)
Number of respondents
2792
ÿ3.02
4.06
2.45
1.26
6.08b
a
Omitted variables are indicated in parentheses. p50.05
based on t-test.
b
According to a likelihood ratio test comparing the above
model with and without the random effect (and correcting for
the fact that the term involving the random effect must be
non-negative), p=0.007.
c
These variables have an additional category (not shown)
for the relatively few respondents with missing information.
References
Bankole, A., Rodriguez, G., & Westoff, C. F. (1996). Mass
media message and reproductive behaviour in Nigeria.
Journal of Biosocial Science, 28, 227–239.
Bhuiya, A., Streatfield, K., & Meyer, P. (1990). Mother’s
hygienic awareness, behaviour, and knowledge of major
childhood diseases in Matlab, Bangladesh. In J. Caldwell, et
al., What we know about the health transition: The cultural,
social and behavioural determinants of health, Vol. I.
Australian National University ([Health Transition Series,
No. 2]).
Burleigh, E., Dandano, C., & Cruz, J. R. (1990). Colors,
humors and evil eye: Indigenous classification and treatment
of childhood diarrhea in highland Guatemala. Medical
Anthropology, 12(4), 419–441.
Caldwell, J. C. (1986). Routes to low mortality in poor countries.
Population and Development Review, 12(2), 171–220.
CELADE (1997). The demographic situation of Central
America. In A. R. Pebley, & L. Rosero-Bixby, Demographic
diversity and change in the Central American isthmus. Santa
Monica, CA: RAND.
Cleland, J. (1990). Maternal education and child survival:
Further evidence and explanations. In J. Caldwell, et al.,
What we know about the health transition: The cultural, social
and behavioural determinants of health, Vol. I. Australian
National University ([Health Transition Series, No. 2]).
Das Gupta, M. (1990). Death clustering, mother’s education
and the determinants of child mortality in rural Punjab,
India. In J. C. Caldwell, et al., What we know about the health
transition: The cultural, social and behavioural determinants of
health, Vol. I. Australian National University ([Health
Transition Series, No. 2]).
Ewbank, D., & Preston, S. H. (1990). Personal health
behaviour and the decline in infant and child mortality:
the United States, 1900–1930. In J. C. Caldwell, et al.,
What we know about the health transition: The cultural,
social and behavioural determinants of health, Vol. I.
N. Goldman et al. / Social Science and Medicine 52 (2001) 53–69
Australian National University ([Health Transition Series,
No. 2]).
Goldman, N., Vaughan, B., & Pebley, A. R. (1998). The
use of calendars to measure child illness in health interview surveys. International Journal of Epidemiology, 27,
505–512.
(1988). Anuario Estadistica ([Guatemala City, Guatemala]).
(1996). Encuesta Nacional de Salud Materno Infantil, 1995.
MD: Macro International.
Lindenbaum, S., Chakraborty, M., & Eias, M. (1985). The
influence of maternal education on infant and child mortality.
Bangladesh: International Centre for Diarrhoeal Disease
Research ([Special Publication No. 23]).
Lindenbaum, S. (1990). Maternal education and health care
processes in Bangladesh: the health and hygiene of the middle
classes. In J. Caldwell, et al., What we know about the health
transition: The cultural, social and behavioural determinants of
health, Vol. I. Australian National University ([Health
Transition Series, No. 2]).
McKee, L. (1987). Ethnomedical treatment of children’s
diarrheal illnesses in the highlands of Ecuador. Social Science
and Medicine, 25(10), 1147–1155.
(1989). Encuesta Nacional de Salud Materno Infantil, 1987.
MD: Macro International.
Montgomery, M. R., & Casterline, J. B. (1996). Social learning,
social influence, and new models of fertility. In J. B. Casterline,
R. D. Lee, & K. A. Foote, Fertility in the United
States ([Supplement to Population and Development Review
22]).
Nathanson, C. A. (1996). Disease prevention and social
change: Toward a theory of public health. Population and
Development Review, 22(4), 609–638.
Palloni, A. (1990). Fertility and mortality decline in Latin
America. In S. H. Preston, World Population: Approaching
the Year 2000 (pp. 126–144) ([Special Issue of The Annals
69
of the American Academy of Political and Social Science,
510]).
Pebley, A. R., Hurtado, E., & Goldman, N. (1999). Beliefs
about children’s illness. Journal of Biosocial Science, 31,
195–219.
Pebley, A. R., Goldman, N., & Rodriguez, G. (1996). Prenatal
and delivery care and childhood immunization in Guatemala:
Do family and community matter?. Demography, 33(2),
231–247.
Peterson, C., Goldman, N., & Pebley, A. R. (1997). The 1995
Guatemalan survey of family health (EGSF): Overview and
codebook. Santa Monica, CA: RAND ([DRU-1538/3NICHD]).
Preston, S. H., & Haines, M. R. (1991). Fatal years: Child
mortality in late nineteenth-century America. Princeton, NJ:
Princeton University Press.
Preston, S. H. (1976). Mortality patterns in national populations: With special reference to recorded causes of death. New
York: Academic Press.
Psacharopoulos, G., & Patrinos, H. A. (1994). Indigenous
people and poverty in Latin America: An empirical analysis.
Washington, DC: World Bank.
Rodriguez, G., & Goldman, N. (1995). An assessment of
estimation procedures for multilevel models with binary
responses. Journal of the Royal Statistical Society, Series A,
158(Part 1), 73–89.
StatisticsEpidemiology Research Corporation (SERC) and
Cytel Software Corporation (1985–1993). EGRET Reference
Manual Revision 4. Seattle: SERC.
Westoff, C. F., & Rodriguez, G. (1995). The mass media and
family planning in Kenya. International Family Planning
Perspectives, 21, 26–31.
Weiss, M. G. (1988). Cultural models of diarrheal illness:
Conceptual framework and review. Social Science and
Medicine, 27(1), 5–16.