By Peter Lloyd-Sherlock, Karla Giacomin, Poliana Fialho de Carvalho, Wanderson Bomfim and Jesilaine Barbosa 

October 2026

Why bathing matters?

Staying clean matters to almost all of us for a variety of reasons -dignity, confidence, as well as mental and physical health. For older people with limited mobility and challenging conditions like dementia, keeping clean is a particular challenge, but there is a surprising lack of research on the issue. Our own RGHI study has found that the obstacles to maintaining personal hygiene in later life are complex and reinforcing, particularly in contexts of poverty (https://rghi.org/tale-of-two-buckets-peter-lloyd-sherlock/). As well as an individual’s capacity, they include the suitability of bathing facilities and whether or not people can access (or are prepared to accept) help from someone else.

Many surveys ask older people if they can bathe without difficulty. Data just published from Brazil’s national survey of older people show one in eight people aged 60 or more admitted to some difficulty in bathing, with higher rates for disadvantaged social groups. But these data tell us nothing about whether people manage to overcome these difficulties and stay clean, or if they are forced to go for long periods without bathing. Given the sensitivity of these issues, surveys and studies avoid asking about older people’s ability to maintain personal hygiene or how frequently they bathe. As a result, we have no data about these things, either for Brazil or anywhere else.

Aside from the distress and stigma it causes, poor personal hygiene in later life is an important public health issue and affects the sustainability of health services. Poor hygiene greatly increases the risk of various types of infection, including urinary tract infections (UTIs). These conditions often become acute, requiring hospital care. A study of Brazilians aged 65 or more found that UTIs accounted for 16.5% of all their hospital admissions (Silva et al, 2021). Also, UTIs have higher rates of resistance to front-line antibiotics than other infections and so they make a disproportionate contribution to the emerging global crisis of antimicrobial resistance (WHO, 2025).

Clearly, it is in all our interests to help older people enjoy the same levels of hygiene as everyone else, so what can be done? A lack of research means a lack of evidence about what works, but our RGHI project has provided an opportunity to start the ball rolling.

Belo Horizonte is one of the two Brazilian cities where we have conducted our study, with a focus on low-income “favela” neighbourhoods. There are many differences between Belo Horizonte and the other study site (Salvador de Bahia) and they include the presence of a local homecare service. Programa Maior Cuidado (PMC) has been operating since 2011. It offers care-dependent older people in vulnerable families weekly homecare visits from care workers who work alongside primary health care and social services (Lloyd-Sherlock et al, 2024). Earlier studies demonstrate PMC works well and does much to improve the lives of older people and family members caring for them (Lloyd-Sherlock et al, 2023; Lloyd-Sherlock et al, 2022). Before our RGHI project, there had been no specific research about the programme’s potential effects on barriers to good hygiene. We had been involved in those earlier studies of PMC and had kept up our contacts with the local government agencies that ran it, so this look like an opportunity to see if well-designed homecare interventions can make a difference.

Belo Horizonte’s Departments of Health and of Social Assistance kindly gave us ethical clearance to work with their care plan data for the 800 plus families included in PMC. They also allowed us to interview and hold focus groups with different people involved in the programme, including PMC care-workers, older people receiving care and unpaid family caregivers.[1]

The care plan data provided a useful overview of families included in PMC and the personal hygiene barriers they faced. The average age of care-recipients was over 81 years old, more than half had symptoms of dementia, most had limited mobility and many were unable to get out of bed. And yet, based on independent monitoring by family primary health care teams, most of these older people were able bathe on a regular basis: at least five times a week in 84 per cent of cases. Only three per cent bathed once a week or less.

How PMC overcomes barriers to bathing.

PMC care workers devote substantial amounts of time to each family -between eight and 20 hours a week, Monday to Friday. These care workers are required to follow personalised care plans agreed between care-receivers, their families, and health and social service staff, and these plans include necessary assistance with personal hygiene. According to a community nurse:

There was one quite shocking case… She hadn’t been able to wash her hair for more than six months. She was very overweight and afraid of falling [in the shower]. When PMC started, she managed to use the shower with the care worker’s help, and wash her hair… Now [with PMC] she can have a shower several times a week.

Many homes lack even basic bathing facilities, or these facilities are not safely accessible for people with disabilities. For example, a PMC care worker referred to the case of an older woman with no mobility and who needed to use a colostomy bag:

She didn’t have a proper bathroom and so we had to improvise a bath right there in her bedroom… I had quite a job heating the water up over the stove and then carrying it to where she was… And, after some time, she couldn’t afford the gas. I had a word with social services… and they were able to sort it out for her.

A key PMC philosophy is that care workers do not replace family caregiving. Instead, they seek to develop effective partnerships with families. In theory, all PMC families include at least one person designated the main caregiver, but in practice their ability to help with bathing was often limited. For example, over 16 per cent of these family caregivers were themselves aged 70 or more and lacked the strength to lift or transfer a full-grown adult. A family caregiver of a woman with very limited mobility told us:

During the weekends, it’s just me here and I can’t carry my mother to the bathroom. She’s over-weight these days… I used to be able to lift her, but not anymore.

In some cases, it took more than one person to help with bathing. A family caregiver of an older man commented:

I used to help him in the shower… but he complained that it left him exhausted and in pain… It’s very difficult to get him in there because of the steps… My sister helps me out, but … she can’t come on weekdays because of work commitments.

As part of this partnership strategy, PMC carers build capacity and work with families to resolve problems:

When the PMC care worker can’t come, like on Saturdays, it’s harder for just me to get her into her [wheel]chair and give her a bath… Still, I feel much more confident and easier about doing it since the care visits started. They have helped so much.

We talked to the family to see if they could make a ramp over the stairs to the bathroom. And we were able to get a shower chair for them to use.

While most older people in PMC are more than willing to bathe on a regular basis, accepting help from another person is another matter. Many feel ashamed and embarrassed about receiving intimate care from another person, be they a relative or a care worker. PMC care workers’ training includes acknowledging and managing this issue with sensitivity:

The first time I came he was a bit, you know… he was a bit against me helping him with his intimate care… He locked himself in the bathroom, things like that… And so, I just kept talking with him… telling him I would use gloves…  that he wasn’t in a position to wash himself on his own. “So, will you give me your permission? I will need to touch parts of you, but I will be very respectful.” And eventually he allowed me to.

Having the power to stay clean is something most of us take for granted, but it can be a daily challenge for many older people with disabilities. The underlying causes of these personal hygiene challenges are complex, especially for poorer populations. Our RGHI project has started to address this neglected issue, showing homecare services like PMC can make an important difference.

[1] We refer to “care workers” and “caregivers” on the basis that the former are paid and the latter not.

REFERENCES

Lloyd-Sherlock, Peter, Karla Cristina Giacomin, Poliana Fialho de Carvalho, and Lucas Sempé 2024. Programa Maior Cuidado: An Integrated Community-Based Intervention on Care for Older People. Interamerican Development Bank Technical Report. https://doi.org/10.18235/0005535

Lloyd-Sherlock P, Giacomin K, Sempé L. The effects of an innovative integrated care intervention in Brazil on local health service use by dependent older people. BMC Health Serv Res. 2022 22(1):176.

Lloyd-Sherlock P, Fialho de Carvalho P, Giacomin K, et al. Addressing pressures on health services in Belo Horizonte, Brazil through community-based care for poor older people: a qualitative study. Lancet Reg Health Am. 2023 27:100619.

Silva J et al (2021) Factors associated with urinary tract infection in a Nursing Home. Rev Bras Enferm. 2021;74 (Suppl 2):1.

World Health Organisation (WHO) Global antibiotic resistance surveillance report 2025: WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) – Summary. Geneva: World Health Organization; 2025. https://doi.org/10.2471/B09585

APPENDIX

Table 1. Self-reported difficulty bathing, using toilet and incontinence for Brazilians aged 60 or more.

Table 2. Percentage of Brazilians aged 60 or more who need help bathing or using the toilet but do not receive it.

Source: Third wave of the Longitudinal Study of the Health of Older Brazilians (ELSI-Brazil), 2023-4.