The AHEAD Model:1
The first stage of the AHEAD Approach is a period (six months – one year), during which the following activities take place:
- Community Mobilisation
- Formation of a Community Health Club
- Base Line Survey
- Health Promotion Sessions
- HIV/AIDS Prevention
- Home Hygiene improvements
1. Community Mobilization:
In order to promote a local sense of ownership of the club as a home grown CBO, the Community Health Club needs to be carefully introduced into an area in the preliminary stages to avoid political suspicion. This is usually done by the implementing agency, (either NGO project officer, or Ministry of Health field worker), in consultation with local leadership (Councilors, politicians, kraal heads, village elders, religious leaders and headmasters) to explain the idea so that the officials are well acquainted with it before the public are involved. The local leaders then call a public meeting and introduce the idea and the implementing partners. The programme is outlined and those interested are invited to meet and register as members of the health club.
2. Formation of Health Clubs:
Membership is voluntary and free, and the club is open to men and women of all ages, religion, levels of education, income and ethnic group. As members can join at any stage of the programme, this encourages wide support. If the club membership exceeds 100, it is often split into two sub groups. At the first meeting, membership cards are issued to each member and plans are made when and where to meet.
The first month is usually dedicated to registering members and establishing the health club leadership. After a few weeks of health sessions, an election is held for Chairperson, Vice Chairperson, Secretary and Treasurer (for future fund raising). The executive committee keeps records of membership and attendance as well as monitoring the facilitator. An inventory of each member’s household (latrine, hand-washing facility, covered water, ladle, soap etc) is done before any session start. This is vital as a base line survey to measure future change.
3. Base Line Survey: the Household Inventory.
Not all programmes are interested in taking time to measure the outcomes of the project. However for the purposes of raising local awareness and fundraising for future expansion it is usually best to establish the existing levels of home hygiene and water and sanitation facilities. Africa AHEAD has developed a community based evaluation system that can be done by the Health club leadership with minimal training. The key indicators of hygiene behaviour change are established before the programme begins. These are then listed and definitions for each indicator clearly established. The CHC facilitators are trained how to recognise these indicators and a recognizable standard is established. At the time of registration each member is visited and their hygiene standards and facilities recorded in a simple register. This can be repeated monthly or at the end of the project and the results quantified. For more sophisticated countries it is possible to use cell phones to upload the household inventory. The data is instantaneously collated and progress in hygiene behaviour within every home can be easily monitored.
J. Rosenfeld & J. Waterkeyn  Using Cell Phones to Monitor and Evaluate Behaviour Change Through Community Health Clubs in South Africa. WEDC International Conference, Addis Ababa.
4. Health Promotion:
Health Promotion is the entry point and first stage. A two hour session is held every week at a regular time and venue decided by the members. A different topic is selected from the membership card according to season and relevance to the area. The members participate in activities that are designed to engage and amuse them as well as provide a forum for debate and full involvement of each member in the decision making process. These activities are recognized Participatory Rural Appraisal/Participatory Hygiene and Sanitation Transformation (PRA/PHAST) training tools using visual aids specifically designed for the area. Those who complete all sessions are publicly recognized with a certificate of full attendance. Each training module takes a minimum of 6 months although this may take up to a year, depending on the season, levels of attendance and need for revision sessions.
Standard participatory PHAST Activities that are done in the health sessions
Role Play and Drama are very effective means of stimulating discussion and are immensely popular. Health Club members participate in role play scenarios about diagnosing a variety of common illnesses and develop dramas about various topics like HIV/AIDS and water, sanitation and hygiene.
Mapping is another very useful activity, which enables health clubs to demonstrate their assets and present visitors with visual information about their area: typically this includes information about the sanitation coverage and water facilities.
Ranking of Needs is participatory activity that enables members to prioritise which of the many issues are the most important to them. A large matrix is drawn on the ground and the ten or more topics of comparison are put along the x and y axis of the matrix. Each topic is compared to the other, and the choice represented in the square with a symbol (e.g. a stone = the need for an access road). When each has been compared with the other, a final total is made of each topic, and the score ranked according to which received the most votes.
Pair-Wise Ranking: Community Evaluation. Groups decide on a number of ways in which the health clubs have benefitted them. They draw a matrix on the ground and put a symbol for each of the ten most common option along each of the y and x axis. They then stand around the edge and chose between the two options, putting the appropriate symbol in the square. When every pair of options has been compared count the total for each symbol and this provides a ranking of which aspects were most valued in the CHC activities.
Blocking the Route is a very effective way to explain the transmission of disease. The faecal-oral transmission of diarrhoea is being discussed and cards show the five main routes by which diarrhoea is spread: fruit, fingers, flies, faeces and food. Each person says what is in their own card. Then other pictures are given out which show ways to block each transmission route. Those who have the appropriate card are asked to come up and explain how their picture can block the spread of diarrhoea and then to stand behind the picture they block. The interventions are then discussed at length and consensus is reached on how they will be able to take steps as a community to reduce diarrhoea.
Three Pile Sorting is an easy game to play if there is a well prepared selection of illustrated cards showing good, bad and medium hygiene practices found in a particular community. The cards are handed out and each person comes up and explains what they have on their card. The audience then discuss whether the card should join the good or bad pile. If they cannot decide the card may be assigned to the medium pile. This exercise promotes lots of discussion and often strong debate as people sort out in their own minds and as a group decide which hygiene practices are really safe. At the end the good practices are ranked and the audience is asked to undertake at least one of the good hygiene ways before the following meeting a week later. This activity builds group consensus enabling ‘common unity’
Song and Slogans: Each health club develops its own songs and slogans to rally the crowd and focus attention on key issues. Making up songs comes so naturally and the pleasure fo singing and dancing together is one of the key activities that harmonise people and bring a sense of common unity.
Sanitation Ladder: Each picture has a different level of sanitation from open defecation (dog sanitation), to covering faeces by digging a hole (cat sanitation), to a basic traditional pit latrine, to a covered /lined pit, then a well constructed permanent pit, a Ventilated and lined pit with a slab, and roof, to a pour flush latrine and eventually to a flushing toilet attached to soak away, and then to sewer system, with some pictures showing a hand washing facility as well. The group is asked to describe each picture, select the ones that are known in the area, and then rank them according to good hygiene. They arrange people each holding a picture from best to worst. Then each person stands behind the picture that shows their own method of sanitation. Then the people are asked to stand behind the model that they would like to have/or could make for themselves. Discussion then focus on how to achieve these improvements.
2. Applying Health Education: Improving Hygiene in the Home
A.H.E.A.D stands for Applied Health Education and Development: the lessons that are learned in the weekly health sessions must be put into practice in the home. Every week at the end of the sessions the key messages are summarized and the club members are asked to decide what ‘homework’ they will be doing that week, associated with something they have learned that day. For example after talking about the storage of drinking water (see above) the homework may be to ensure that everyone covered their drinking water container properly. A health club members home can be identified by many important hygiene facilities and the overall standard of cleanliness ti much higher than those who do not attend the club meetings.
- Clean and beautiful kitchens
- Individual plates and cups for each family member
- Water Stored safely in clean and sealed containers
- Good sanitation: clean and well maintained latrines
- A hand washing facility with soap available
- A well swept compound and rubbish pit for solid waste
- ZOD: Zero open defecation around home
- A bathing shelter with good drainage
- Making soap to ensure ready availability
5. HIV/AIDS prevention
Knowledge on prevention of HIV/AIDS has increased in recent years and we are beginning to see a fall in new cases in some countries. However, whilst most people are now aware of the causes of HIV/AIDS, there is often little change in risky practices due to the combination of high alcohol consumption and migrant labour. Considerable time is spent discussing issues related to HIV/AIDS. The Health Club becomes one of the most proactive local institutions for providing information about AIDS and often practical assistance in the distribution of condoms. It also contributes towards breaking the taboos on the use of condoms and enabling women to discuss how to encourage their partners to use this methods, and how to deal with religious and traditional leadership that discourage the use of condoms.
6. Home Hygiene Improvements:
The Community Health Clubs are not just talking shops where a lot is learnt and little is done. Each week there is a little practical ‘homework’ to be done, related to recommended practises to ensure prevention of the disease under discussion. Members pledge to make small changes in their own homestead before the next meeting the following week – the digging of a refuse pit, the making of a dish rack for drying plates off the ground, some means for covering drinking water, the commitment to wash hands in a more hygienic manner. This systematic approach ensures that hygiene progress is made each week. Recommendations usually require no financial outlay but merely reorganisation in the home and better hygiene practise. Behaviour change is sustained by peer pressure and levels of adherence to recommended non-risk practices are exceptionally high. Health Club hygiene has been monitored and cost effectiveness has been well documented over the past decade.
Waterkeyn, J. (2005). Kampala, 31st WEDC Conference