Across low and middle-income countries like Brazil, populations of older people are increasing very rapidly. Maintaining good personal hygiene is important for all of us, and there are particular reasons for keeping this up in later life. Older people are more susceptible to health conditions associated with poor hygiene, like urinary tract infections, diarrhoea or pressure sores. Staying clean is especially challenging for older people with continencey problems, or who struggle to remember or to wash without help. These challenges are even greater in slum neighbourhoods where bathing facilities are often rudimentary.

Last month, members of our research team started to visit older people in some of Salvador’s poor favela neighbourhoods. Our main purpose was to pilot research tools (questionnaires and interviews) which we plan to roll out later in the year. Here are two stories about people we met.

Dona Aparecida’s determination¹

Dona Aparecida is 84 years old, widowed and lives alone in a small, poorly ventilated shack. Considering her advanced age and hard life, she is in remarkably good health. Nevertheless, she is increasingly frail and her memory is less good than it used to be. Dona Aparecida’s sight is failing, but she hasn’t been able to visit an optician. This isn’t surprising -she struggles with stairs and the entrance to her house has a steep, uneven set of steps.

Maintaining good hygiene is very important to Dona Aparecida, but it is becoming increasingly difficult for her. She has a small bathroom, but no hot water. Like many older people, Dona Aparecida struggles with stiffness, aches and pains which are exacerbated by cold bathing. And so twice a day she boils pans of water on her stove, pours them into a large, heavy bucket in her cramped bathroom and washes herself down with cheap soap. About once a week, Dona Aparecida washes her hair with the same soap under a cold water tap in her outside yard -shampoo an unaffordable luxury.

Still managing two baths a day is a matter of pride and self-esteem for Dona Aparecida. She tells us that she has done this all her life and is determined not to let it slip: “It’s so important for people to get a proper bath at least once a day, you know.” Nevertheless, it is hard to imagine how she will be able continue this routine without increasing help.

Dona Maria’s crisis

Dona Maria lives a few miles away, in a similar neighbourhood of steep, narrow alleys and informal housing. She remains in quite good physical health for her 86 years, but is a little unsteady on her feet and has to use pads to avoid toilet accidents. Sadly, there are clear signs that she is experiencing dementia, although there has been no opportunity for this to be diagnosed by a professional. We mainly speak with one of her four children, Lucia, while Dona Maria sits by her side showing no sign she is following our conversation.

Like Dona Aparecida, Dona Maria’s home lacks hot water and so her family also heat buckets of water for her to bathe twice a day. Though physically able to wash, bathe and brush her own teeth, she will not do so unless reminded. Lucia persists with this, as she takes a special interest in hygiene routines – a few years ago, she took a course in oral health at the local health centre. Lucia tries to strike a balance between providing help and respecting her mother’s independence and dignity: “I stand just outside the bathroom while she washes, just in case she needs anything… Mum manages to wash herself, but I hover there worried she might have an accident, just in case she needs something. But I avoid going in. I try to leave her to it.”

When we ask Lucia if her mother continues to take an interest in her hygiene or appearance, her reply is unexpected. As a younger woman, Dona Aparecida had taken a lot of pride with these things, but this had changed about 20 years ago. At that time, her husband had violently assaulted her, for which he served a short period of prison time. According to Lucia, this provoked a deep personal crisis for Dona Aparecida from which she never recovered. She became profoundly depressed (which went undiagnosed and untreated), losing interest in everything, including her appearance. Since then, Lucia has had to cajole and remind her mother to look after herself. Looking after Dona Aparecida has become a full-time job for Lucia and her sisters: “But she’s our family, our flesh and blood. It’s our duty to help care for her, and make sure she’s never left to do this on her own.”

Reflections

Our pilot visits did the job they were intended for, and we have been able to tweak some of our data collection plans for the main surveys.

But more importantly, they made us more aware of the complexity of the issues we are studying. On the surface, both these women might be considered hygiene “success stories”, as they continued to bathe twice a day in the face of considerable challenges. But their stories reveal a much more complex intersection of effects including poverty, mental health, frailty and gender dynamics. It looks like we have just scraped the surface…

[1] The names of the people we visited have been changed.