Our name ‘A.H.E.A.D’, stands for our strategy: Applied Health Education and Development, which summarises our methodology – the holistic development of a community in four phases: using health promotion through Community Health Clubs as an entry point into communities; then applying this knowledge by improving hygiene, water and sanitation in the second year. This practical application usually evolves in the 3rd year, into to a ‘Livelihoods’ programme to ensure food security and development of skills, and finally in the 4th year to complete community management of wider social development issues, such as AIDS, substance abuse, child rights, domestic abuse and human rights.
Rationale for the CHC Model
The CHC Model works because it provides a structure within which the whole group can endorse decisions, thus removing any individual fears or risks of ‘going it alone’. this strategy is different from the ‘trickle down approach’ whereby a few ‘enlightened’ individuals slowly influence others to adapt. Whilst this may ‘work’ where technology is concerned (like the rapid spread of the use of cell phones) for less ‘sexy’ issues such as sanitation it is not a cost effective method of changing society. Community Health Clubs provide a forum for discussion leading to group consensus and the whole group rises up together. When a critical mass of people within the health club decide to do something, the rest will follow even if they do not appreciate all the reasons.
The CHC Model of Development is:
- STRUCTURED: A known membership within a Community Health Club: a committed group formed specifically to promote health rather than a loose gathering of people addressed ad hoc.
- MEASURABLE: Topics, key messages and targets are set in a syllabus summarised in a membership card.
- REGULAR: club holds weekly health sessions for at least six months.
- GROUP CONSENSUS: appeals to group consensus and peer pressure rather than targeting individuals.
- INCLUSIVE : uses health as the ‘entry point’ because knowledge can be shared infinitely, rather than aid programmes which divide as communities compete for limited handouts.
- PARTICIPATORY: members use lively Participatory Techniques that promote enable self realisation rather than top-down directives.
- HOLISTIC: addresses a myriad of diseases that can be prevented by good hygiene rather than one specific disease (diarrhoea).
- HORIZONTAL: A wide focus of all causes of ill health, including poverty, rather than vertically targeting a few issues such as diarrhoea.
- LONG TERM: constantly reinforces key messages through focus on 24 different issue in stage one and continues to apply information in subsequent stages.
Development is a Process not a Quick Fix
The AHEAD Model is based on the understanding that people take time to adapt and that change is best realised in stages. The initial focus on ensuring community cohesion through structured health promotion activities has proven to be ‘the missing link’ that can help achieve sustainable development. Enabling a community to become self-sufficient, has been rationalised into a series of stages, so as to ensure the community are not over burdened by too much development at once and that each initiative is a natural progression from the last. So, knowledge gained in health sessions leads to improved hygiene facilities and safe water and sanitation. Once a dedicated group has been working together for some time (over a year) they are better able to handle the demands of coordinating an income generating project. The income that is generated in terms allows members to have a little surplus and encourages altruistic initiatives by the community themselves to take responsibility for vulnerable families within their area. This 4 stage process is actually the steady manufacture of Social Capital, which is vested in the health club but provides a safety net for all members of the community, whether members or not.
Stage 1: HEALTH EDUCATION AND HYGIENE PROMOTION
The health and survival of one’s children is a universal concern, therefore providing the opportunity for the whole community to take control of their health is a viable entry point. Although some argue that people are not interested in knowledge, this programme has demonstrated that there is usually an incredible respect for education within poorer communities and that they welcome any opportunity to learn. Within six months, members gain a basic understanding of the germ theory, and know the transmission, prevention, and cure of all preventable diseases, which are discussed one topic per week for at least 24 weeks. Every session is combined with simple, inexpensive and do-able changes that people can make to their lives without external assistance. The first six months of ‘cleaning up one’s own home’ based on new understanding of the importance of hygiene is easy and provides the foundation for more difficult projects which need outside assistance like the upgrading of water and sanitation.
Stage 2: UPGRADING WATER AND SANITATION
Usually before the six month of health promotion sessions has been completed, a demand for safe water and sanitation has been created, so that there is not a situation where project planners have to foist their unwanted services on resistant beneficiaries. The club members are organised and pro-active and can easily manage water and sanitation programmes themselves and project planners are partners rather than donors. It has been shown that by delaying the introduction of the ‘hardware’ (water and sanitation) until the ‘software’ (training) has been done, significantly increases the sense of community ownership, and prevents vandalism of water and sanitation facilities, so ensuring more sustainability.
Stage 3: SKILLS IMPROVEMENT AND POVERTY ALLEVIATION
Income generating projects are only available for those that have gained their certificate of full attendance at the health sessions. This ensures that only hard working ‘bone fide’ members will have this sought after priviledge, and this rule (originally instigated by the CHCs not AFRICA AHEAD) has insured countless times, that unscrupulous opportunists within the community do not profit unfairly without doing their time in the club. At this stage men in particular are forced to go through the training in order to join the popular projects, thus increasing density of membership and related health knowledge throughout the community. Each CHC goes through a needs assessment process using PRA, and identifies projects that are feasible. The NGO may provide a start up training and relevant equipment. Some of the many projects that hve been started in CHCs can be seen below: vegetable growing, herb production, oil pressing, peanut butter making, sewing uniforms, batiks and handicrafts, soap making, paper making, goat rearing and many other self help projects, which have been running without any outside assistance. All these activities increase their skills, provide employment in the home, enabling them to sustain their livelihoods and be self reliant.
Stage 4: SOCIAL RESPONSIBILITY
Once the community reaches this stage of organisation and generation of income, it is time to start looking at some of the deeper issues. Who are the vulnerable families and how can the community support them? – are there orphans, widows, disabled and elderly who are struggling? What are some of the social problems in the community that are undermining families? – typically there are problems of alcohol/drug abuse, gender issues such as domestic violence and insecurity, lack of self confidence, low self esteem and the need for literacy to increase self-efficacy or a play school to enable children to be cared for while mothers work.
The AHEAD Approach is a training methodology that aims to develop functional communities by modifying the determinants of health to ensure long-term hygiene improvement through positive behaviour change. The process ensures that communities are not just a loose collection of households within a geographical area, but that they arestrongly bonded neighbourhood, defined by a ‘common unity’ of understanding on health and most importantly, the households have the capacity to act together effectively to improve family health. Two important observations underlie the reasons for using this approach:
1.Most women are primarily interested in caring effectively for their family and will therefore be interested in the opportunity to improve their ability as mothers.
2.There is an intellectual starvation in developing communities, and many people have not had sufficient opportunity to learn, so they will respond to health information.
These observations have been substantiated by qualitative research,which has confirmed that many rural communities lack the opportunity for women in particular to come together regularly to understand their problems and work together to change and improve their lives.
To meet this need a system has been developed that assists communities to start up community based organizations which can provide a regular forum for parents (mothers in particular) to meet and discuss key concerns in their lives. This is a forum where people meet weekly and through participating in problem solving activities they develop a common understanding of health issues, based on shared information and beliefs. They adhere to certain positive practices which become a way of life. This is achieved through participatory activities which enable bottom-up sustainable solutions to be found.
Health Promotion seeks to change people’s hygiene behaviour. In the industrialised world, personal change is usually an individual act. However in largely ‘traditional’ rural communities the individual is perceived as less important than harmony of the whole: personal freedom is not often encouraged as it may divide society. In the past, development programmes have tended to appeal to each individual to change.This has ignored the fact that from a community perspective, an individual act will challenge the norm, which can start a chain of jealousy. The Community Health Club intervention uses the opposite tactic.If a decision is endorsed by the whole group, then the individual within the group can make the change, and need have no personal fear. Thus group consensus is achieved when all the individual members agree to conform to recognised standards adopted by the group.
Community Health Clubs aim to create a ‘common unity’ of understanding and shared perceptions of disease, within an area. Social pressure and group conformity are, in this model, seen as more potent change agents than is the mere appeal to individual rationale through cognitive learning, although the later is also recognised as being important. By adjusting norms and values, this health promotion strategy creates a ‘culture of health,’ which enables women to successfully control most preventable diseases and manage their family’s health. By constant reinforcement of key messages, bolstered by group consensus, Community Health Clubs can develop self-efficacy enabling members to successfully challenge existing cultural practices that undermine good health.If the critical mass in a community change their core values and beliefs based on informed decisions, late adopters are likely to conform for social reasons. Thus positive behaviour change in hygiene is reasonably predictable if a person is an active member in a dynamic Community Health Club.