PUBLICATIONS

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The definitive book on Community Health Clubs is now available :

Waterkeyn, J. (2010) Hygiene Behaviour Change through the Community Health Club Approach: a cost effective strategy to achieve the Millennium Developments Goals for improved Sanitation in Africa. Lambert Academic Publishing. Germany. ISBN: 978-3-8383-4491-1

Abstract: Good hygiene and sanitation are critical for improving family health, but most rural communities in Africa have shown little inclination to change their traditional high risk behaviour patterns, resulting in high infant mortality due to preventable diseases. With the Millennium Development Goals seeking to halve the 2.4 billion people without sanitation by the year 2015, there is an urgent need to find cost- effective health promotion strategies that will actively engage rural householders to improve their hygiene practices. This study demonstrates that health promotion can be an effective entry point into holistic and sustainable development. Through regular training in Community Health Clubs, conventional norms and values are altered, resulting in hygiene behaviour change and a demand for sanitation. As a failed state Zimbabwe provides a test case in the sustainability of the approach, showing how health clubs , with minimal support, have empowered women to take control of their lives enabling survival in the face of hyperinflation, food shortages and HIV/AIDS. The Community Health Club Approach is now being replicated in many countries in Africa and Asia.

A CD is now available from Africa AHEAD (US$20) with all the publications listed below. contact juliet@africaahead.com

Waterkeyn, J (2006).Cost-effective Health Promotion and Hygiene Behaviour Change through Community Health Clubs. PhD Thesis. Submitted to London School of Hygiene and Tropical Medicine

Abstract: Although safe sanitation and hygiene is critical for improving family health, rural communities in Sub Saharan Africa have shown little inclination to change their traditional behaviour, and sanitation coverage has now dropped to 47% (Cairncross 2003). With the Millennium Development Goals seeking to halve the 2.4 billion people without sanitation by the year 2015, there is an urgent need to find cost-effective health promotion strategies that will actively engage rural householders in modifying risky hygiene behaviour. This thesis evaluates an approach, developed over the past ten years in Zimbabwe, in which Community Health Clubs have successfully galvanised rural communities into active behaviour change leading to a strong demand for sanitation. In Tsholotsho District, after six months of weekly hygiene promotion sessions, at the cost of US 35c per beneficiary, good health knowledge of nine different topics was 47% higher in the intervention than for the control, and latrine coverage rose to 43% contrasted to 2% in the control area, with the remaining 57% members without latrines practicing faecal burial, a method previously unknown (p>0.0001). Spot observations of 736 Health Club households in two districts was contrasted to 172 in a control group, and showed highly significant changes in 17 key hygiene practices (p>0.0001) including hand washing. The study demonstrates that if a strong community structure is developed and the norms of a community are altered by peer pressure from a cyclical to linear world view, hygiene behaviour change will ensue and a demand for sanitation can be created. Maslow’s Hierarchy of Needs (1954) is adapted to a rural context to analyse the qualitative data, providing some insight into the socio-cultural mechanisms at work. Despite adverse socio-economic conditions in Zimbabwe over the past five years, Health Clubs have flourished, providing a sustainable and cost-effective case study.

Waterkeyn J. (2006) District Health Promotion using the Consensus Approach. WELL/DFID/ London School of Hygiene and Tropical Medicine.

Summary: This 25 page manual is a guideline for those planners looking for a practical methodology for conducting a health promotion project at District Level. The focus is primarily on applying this approach to rural areas; however the approach is still applicable to an urban setting. The manual takes approximately 1 ½ hours to read and is divided into three main sections:

Waterkeyn, J. (2006) Scaling up Community Health Clubs: An Appeal to Funding Agencies. WELL/ London School of Hygiene and Tropical Medicine.

Abstract: It is now over a decade since the first Community Health Clubs were started and their effectiveness in creating a demand for sanitation and rapid uptake of recommended hygiene practices is beginning to be appreciated in the academic world following recent research at the London School of Hygiene and Tropical Medicine (Waterkeyn and Cairncross, 2005). Looking at comparative programmes it is clear that Community Health Clubs are one of the most cost-effective methodologies for achieving hygiene behaviour change in rural areas of Africa (WSP. 2004), and that the highest rate of change can be expected in the less developed areas. In 2004, Africa AHEAD Association was founded by the author, to replicate and adapt the CHC Approach throughout Africa by starting pilot projects in as many countries as possible to provide first hand models for the development community. The following three examples show the ability of this methodology to go to scale and challenge development agencies to provide resources to scale up this proven methodology in order to meet the MDG targets for water and sanitation.

For full article in pdf, click here: Scaling Up Community Health Clubs: An Appeal to Funding Agencies

PEER REVIEWED PAPERS

Waterkeyn JAV and Waterkeyn AJ (2013) Creating a culture of health: hygiene behaviour change in community health clubs through knowledge and positive peer pressure Journal of Water, Sanitation and Hygiene for Development Vol 3 No 2 pp 144–155. contact: juliet@africaahead.com

Abstract: Understanding the mechanisms that trigger behaviour change to overcome risky hygiene is critical to improving family health. Research in an integrated health promotion programme in 382 Community Health Clubs (CHCs) in three districts of Zimbabwe showed clearly the value members attached to gaining ‘knowledge’, which was their strongest motivation for joining CHCs. In these rural areas, where only 38% had completed primary school, randomly sampled CHCs ranked the ‘Need for Knowledge’ second highest after ‘Safety’. A survey of 880 CHC members showed that an average of 80% of CHC members who had ‘full knowledge of diarrhoea’, also practised ten recommended hygiene practices (P > 0.001), compared to 17% who had ‘some knowledge’, and 6% who had safe hygiene, but ‘no knowledge’. In the control group only 50% with ‘full knowledge’ of diarrhoea, also practised safe hygiene, 30% fewer than the CHCs. Therefore, thorough training is needed to ensure a critical mass have ‘full knowledge’. This justifies the CHC Model with 24 weekly sessions reinforcing key messages over a six month period. Positive peer pressure through shared knowledge, understanding and experience, combines to change group values ensuring that even uninformed individuals adopt safe hygiene practices through the adoption of a ‘Culture of Health’.

For full paper click http://www.iwaponline.com/washdev/003/washdev0030144.htm

Waterkeyn, J. & Cairncross, S. (2005). Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts of Zimbabwe. 61. Social Science & Medicine.1958-1970

Abstract: Unless strategies are found to galvanise rural communities and create a demand for sanitation, we cannot achieve the Millennium Development Goal of halving the 2.4 billion people without sanitation by the year 2015. This study describes an innovative methodology used in Zimbabwe – Community Health Clubs – which significantly changed hygiene behaviour and build rural demand for sanitation. In one year in Makoni District, 1,244 health sessions were held by 14 trainers, costing an average of US$0.21 per beneficiary and involving 11,450 club members (68,700 beneficiaries). In Tsholotsho District, 2,105 members participated in 182 health promotion sessions held by 3 trainers which cost US$ 0.55 for each of the 12,630 beneficiaries. Within two years, 2,400 latrines had been built in Makoni, and in Tsholotsho latrine coverage rose to 43% contrasted to 2% in the control area, with 1,200 latrines being built in 18 months. Although Zimbabwe has historically relied on subsidies to stimulate sanitation, this intervention shows how total sanitation could be achievable; the remaining 57% Club members without latrines in Tsholotsho all practised faecal burial, a method previously unknown to them. Club members’ hygiene was significantly different (p < 0.0001) from a control group regarding 17 key hygiene practices including hand washing, showing that if a strong community structure is developed and the norms of a community are altered, sanitation and hygiene behaviour are likely to improve. This methodology could be scaled up to contribute to ambitious global targets.

PAPERS PRESENTED AT CONFERENCES:

2011: Africa San Conference, Kigali, Rwanda Hygiene Behaviour Change in Rwanda. Presented by Joseph Katabarwa

2009: IWA (International Water Association) Conference, Mexico. Waterkeyn.J, Matimati.R and Muringaniza.A. ZOD for all – Scaling up the Community Health Club Model to meet the MDGs for Sanitation in Rural and Urban areas : Case Studies from Zimbabwe and Uganda.

Abstract: Most countries in Africa will fall short of meeting the MDG targets for the provision of water and sanitation due to lack of financial and institutional capacity (WSP-Africa, 2006). Although safe sanitation has been found to be the most effective single intervention in reducing diarrhoea (Esrey, et al.1991), this does not necessarily mean building latrines, which can become a fly breeding ground if they are not sealed properly. The faecal-oral route can be broken more easily and a lot more cost-effectively through faecal burial (cat sanitation) and hand washing with soap (Curtis & Cairncross, 2003). After over a decade of pilot projects in many countries in Africa the Community Health Club (CHC) Approach has proved itself as a cost-effective model for health promotion which can reasonably predict behaviour change, creating a strong demand for sanitation and a‘Culture of Health’ that insures good hygiene (Waterkeyn & Cairncross, 2005). New data from Zimbabwe shows once again high levels of community response through Community Health Clubs. In the rural areas of Chipinge District, the concept of ‘ZOD’ (Zero Open Defecation) has been enthusiastically endorsed by CHCs proclaiming their areas free from open defecation. In these evangelical Christian areas ‘Cleanliness is next to Godliness’, so ZOD is next to God. 37 Community Health Clubs with 2,388 members not only achieved ZOD, but also a 44% average improved hygiene behaviour change of 17 different proxy indicators within twelve months (Zimbabwe AHEAD, 2008). To demonstrate how the main principles of CHCs have been adapted to emergency programmes in urban areas, two other case studies are cited in this paper. In IDP Camps in Uganda (2005), over 11,000 latrines were built in eight months by Community Health Club members (Waterkeyn & Okot, 2005). In Zimbabwe, 36 CHCs brought a cholera epidemic under control in Sakubva, a high density suburb of Mutare, by a massive cleanup of solid waste and widespread adoption of hygienic behaviours. This paper demonstrates how hygiene promotion can create demand driven sanitation through Community Health Clubs, providing four different options for scaling up health promotion depending on the availability of trainers. The reduction of diarrhoea through sanitation is but one of many possible outcomes when mobilising communities through CHCs. In Rwanda, the Ministry of Health plans to scale up the approach to national level and establish CHCs within all of the 15,000 villages in the country not only to address sanitation, but to reduce infant mortality and alleviate poverty (MoH, Rwanda, 2009).

2009: Zimbabwe Case Study : Cholera Prevention in Mutare

Most countries in Africa will fall short of meeting the MDG targets for the provision of water and sanitation due to lack of financial and institutional capacity (WSP-Africa, 2006). Although safe sanitation has been found to be the most effective single intervention in reducing diarrhoea (Esrey, et al.1991), this does not necessarily mean the building of latrines, as these can become a fly breeding ground if they are not sealed properly, and further compound the spread of diarrhoea. The faecal-oral route can be broken much more easily and a lot more cost-effectively through faecal burial and hand washing with soap (Curtis & Cairncross, 2003). After more than a decade of pilot projects in many countries in Africa the Community Health Club (CHC) Approach can reasonably predict behaviour change, and ensure zero open defecation and handwashing with soap. By creating a strong demand for safe sanitation and a ‘Culture of Health’ that insures good hygiene (Waterkeyn & Cairncross, 2005) Community Health Clubs can become a potent mobilisation strategy in emergencies not only in rural areas but, as this case study shows, in urban areas as well. During the cholera outbreak that affected 12,700 people and claimed 420 lives in Zimbabwe, the a high density suburb of Sakubva, in Mutare, only had 4 cases and no deaths. This has been attributed to an environmental clean-up and improved the hygiene behaviour due to the efforts of 5,400 members in 36 Community Health Clubs.

2009 International Water Association Conference, Mexico City. Monitoring Hygiene Behaviour Change Through Community Health Clubs. Juliet Waterkeyn & Jason Rosenfeld (2009)

Abstract: Umzimkhulu Municipality in Kwa Zulu Natal Province has one of the lowest levels of development in South Africa. The base-line survey highlights that only 15% of households have access to a safe water source whilst the remaining households have to use open ground water, usually in the form of unprotected springs. Sanitation usually consists of a household pit latrine. Although the coverage is high at 90%, around 50% were unhygienic and attracted flies. A health promotion campaign was introduced to build the capacity of the community, with the objective of developing a community-led demand for improved water and sanitation. As the Community Health Club Approach is known to be capable of achieving high levels of behaviour change (Waterkeyn & Cairncross, 2006) it was chosen as the strategy for a health promotion campaign in nine wards of Umzimkhulu. Although Africa AHEAD has initiated Community Health Clubs in informal settlements in Cape Town, this is the first pilot project in South Africa to be implemented in a rural community.

2009: WEDC Conference, Addis Ababa. Waterkeyn, J .Structured participation in Community Health Clubs

Abstract: Water and sanitation practitioners are challenged not only with developing interventions to enable the Millennium Development Goals to be reached, but also to show that their projects have achieved sustainable hygiene behaviour change. However, logistical limitations of existing data collection techniques have constrained the measurement of hygiene behaviour change. For over a decade the Community Health Club approach has proven that measuring behaviour change is feasible and can easily be performed through community-based monitoring. As the originator of this methodology, a South African based NGO is further refining an already robust monitoring and evaluation plan by using an innovative tool called the Mobile Researcher platform. This involves the use of cellular phones to conduct research and is proving an ideal tool for conducting community-based research in rural Africa, as demonstrated in the Integrated Water Resource Management project in South Africa.

2008. WISA (Water Institute of South Africa) Durban. Rosenfeld, J. Incremental Improvements to Community Water Supply Systems through Community Health Clubs in the Umzimkhulu Local Municipality.

Abstract: According to recent assessments, Africa as a whole is currently on track to reach Goal 7of the Millennium Development Goals, while South Africa in particular already halved the number of people without access to safe water in 2005. Despite this achievement, many rural communities throughout South Africa still lack access to this vital resource, which is exacerbated by a culture of dependency on and institutional limitations of local governments. One such area is the Umzimkhulu Local Municipality of the Sisonke District of the Kwa-Zulu Natal Province, where approximately 66% of the population has no access to water infrastructure of any kind and 99% have access below the RDP standards. To address this gap in coverage, AfricaAHEAD, under the Department of Water and Environmental Affairs’ Integrated Water Resource Management project, piloted a Community Health Club (CHC) project to show how the CHC Approach can be utilized to address the historical backlog of water and sanitation service delivery in this rural municipality through the promotion of self-supply water schemes. After six months of structured WASH promotion, three out of the nine CHCs took the initiative to incrementally improve their available water sources and thereby began independently climbing the Water Ladder, while 59% of member households began boiling their household’s drinking water. Through a process that changes social norms via structured communal dialogue and peer pressure, the CHC Approach provides communities with a platform from which they can unchain the shackles of dependencies and chart their own developmental course.

2008 WISA (Water Institute of South Africa) Durban. Rosenfeld, J. Incremental Improvements to Community Water Supply Systems through Community Health Clubs in the Umzimkhulu Local Municipality.

2008 WISA (Water Institute of South Africa) Durban. Maksimoski, N & Waterkeyn, A. The Community Health Club Approach in Informal Settlements: Case study from eThekwini Municipality, Kwa Zulu Natal, South Africa

The Community Health Club (CHC) Approach promotes sustainable and holistic community development by providing a structured learning environment for health promotion and water and sanitation activities. Although research has shown the CHC approach to be cost-effective in achieving continued behaviour change in numerous locations in Africa, most projects to date have been implemented in a rural context. Most recently, there has been interest to apply this methodology to informal settlements in South Africa. To determine if it is possible to translate the success of CHCs to this setting, Africa AHEAD, under the eThekwini Municipality’s Department of Water and Sanitation, implemented a pilot project in the peri-urban informal settlement of Johanna Road. Although only at mid-point, tangible results such as a 75.6% increase in zero open defecation among CHC members, a 50% reduction of non-sanctioned dumping sites in the settlement, and increased health, hygiene, and sanitation knowledge in the community suggest that the CHC Approach is appropriate for informal settlements. While change has occurred in a remarkably short time, alterations to the implementation strategy proved necessary in order to adapt the methodology to this context.

2008 WORLD WATER WEEK, Stockholm (2008) Waterkeyn. A. CHCs with a focus on Urban Areas: two case studies (Zimbabwe and Uganda)

Uganda IDP Case Study Zimbabwe Case Study : Cholera Prevention in Mutare

In 2005 Community Health Clubs were started in IDP Camps in Northern Uganda, where numerous NGOs had been trying to introduce safer sanitation for the past 18 years in one of the worst ongoing conflicts in Africa. In spite of much skeptism that nothing could be done to alleviate this chronic public health situation, the 120 CHCs managed to achieve unheard of changes in the camps, with the most convincing indicator being the construction by the community of over 11,000 latrines in eight months, not only meeting but exceeding ambitious targets. If ever there was a proof of the effectiveness of CHC to create a demand for sanitation this case study is it!

2005 31st WEDC Conference, Kampala Okot. P, Kwame. V & Waterkeyn. Rapid Sanitation Uptake in the Internally Displaced People Camps of Northern Uganda through Community Health Clubs.

Powerpoint presentation

Abstract: One of the worst humanitarian disasters in the world is currently taking place in Northern Uganda where 89% of the population in Gulu District now live in 33 Internally Displaced People’s (IDP) Camps, with low levels of home hygiene and only 5% sanitation coverage. A local NGO, Health Integrated Development Organization (HIDO), has started 116 Community Health Clubs in 15 IDPs camps, with 15,522 regular members who meet weekly for hygiene sessions. Within 4 months, health club members have constructed 8,504 latrines, 6,020 bath shelters, 3,372 drying racks, and 1,552 hand washing facilities, with an estimated 100,000 direct beneficiaries. The strategy has been based on the A.H.E.A.D Community Health Club Approach using participatory PHAST training tools, and may provide a cost-effective model for future IDP emergency sanitation programs.

2005 31st WEDC Conference, Kampala Waterkeyn, A. Hygiene & Sanitation Strategies in Uganda: How to achieve sustainable behaviour change?

Abstract: Breaking the faecal-oral disease transmission route is a vital first step towards overcoming preventable disease and, ultimately, poverty. Simple knowledge transfer, whatever methodology is employed, does not automatically result in changed or improved behaviour. There is growing consensus that to achieve behaviour change in hygiene and sanitation practices communities, both rural and high-density peri-urban, need to be supported in ways that will stimulate social cohesion and result in group decisions being taken. Such cohesion and the building of social capital can ensure that peer pressure comes to bear and poor hygiene practices can thus be challenged. This paper considers several approaches to Hygiene Promotion and Sanitation that are currently receiving attention. It attempts to tease out some of the common threads that appear to be stimulating social cohesion and peer pressure towards achieving behaviour change that will be sustained and also considers the current hopeful situation in Uganda.

2005 31st WEDC Conference, Kampala Waterkeyn, J. Decreasing Communicable Diseases through Improved Hygiene in Community Health Clubs.

Abstract: Community Health Clubs in Zimbabwe have proved an effective way to sustain hygiene behaviour change. In 2001, a survey of households indicated significant improvement in hand washing, safe sanitation, good water protection and food hygiene showing 16% difference between health club and control areas (p>0.001) in Makoni and 50% in Tsholotsho District. (Waterkeyn 2003) Recent research confirms that in areas of high coverage of health clubs, there have been significant decreases in reported clinical cases of communicable diseases over the past nine yeas. In Ruombwe, where health clubs have been operating since 1995 and where 80% of the households have members, diarrhoea has fallen from 404 cases in 1995 to 38 in 2003, and Bilharzia almost eliminated from 1,310 in 1995 to only one case. In addition, acute respiratory diseases have decreased from 2,136 to 159 and skin diseases have fallen from 685 to 41 in 2003

2004 WSP-EA/World Bank. Waterkeyn, A. & Waterkeyn, J. Report: Taking PHAST the Extra Mile Through Community Health Clubs

Abstract: The current concern over the lack of cost-effectiveness of PHAST in East and Central Africa prompts us to enter the debate to argue that PHAST should not be abandoned as it can be very effective if it is taken the extra mile. The programme described below is a variation of the PHAST Methodology and was implemented by Zimbabwe AHEAD, a local NGO, during the same period as the national PHAST training was taking place through the Ministry of Health in Zimbabwe. The NGO was working closely with UNICEF in the initial phase of the PHAST programme and was a major contributor to the National PHAST Tool Kit which was used throughout the country for training. The PHAST programme in Zimbabwe was substantial with over 9,000 trainers introduced to PHAST, but in the long term this did not translate into community programmes except in two districts. However, the cost-effectiveness of hygiene behaviour change could not be assessed accurately as the target audience was ill-defined and the outputs were unspecified and unmeasurable. In view of this, the NGO sought to ‘add value’ to PHAST by developing a system of monitoring and evaluation that is able to quantify levels of behaviour change. This methodology sought to use the standard participatory training method of PHAST but within a more structured programme i.e. ‘structured participation’. Health promotion is the entry point into a four stage process which has become known as the AHEAD Approach (Applied Health Education and Development). Community Health Clubs are the ‘vehicle’ for hygiene promotion with the benefit of having a consistent membership who attend health sessions weekly and who are monitored using membership cards. The concept of the ‘club’ is a subtle but important difference between this approach and standard PHAST interventions. In addition, a structured ‘syllabus’ of health information is followed with standardised recommended hygiene practices for each member. Thus PHAST is ‘repackaged’ into a methodology that has now shown itself to provide the missing ‘social’ link that is needed if we are to persuade people to change their behaviour. (Waterkeyn,1999, 2000, 2003) To evaluate the cost-effectiveness of the AHEAD approach, an extensive survey was conducted in three districts of Zimbabwe in 2001, with 1,250 health club members and a control of 260 non members, with spot observations of randomly selected households. Taking an average of the eighteen observable proxy indicators, there was a significant difference between health club members and non members of 50% in Tsholotsho, 18% in Makoni, and 7% in Gutu (p=>0.001). Health Knowledge increased by 48% in Tsholotsho, 20% in Gutu and 8% in Makoni. In many cases particularly in Tsholotsho, the difference was highly significant with 92:3% for pouring method of handwashing, 95:46% use of ladle, 97:22% for use of individual plates and 86:10% use of individual cups, whilst cat sanitation increased from nil to 57%, with an increase of latrine construction of 40% (p=>0.001). It has been calculated from detailed project records that in Makoni District where 14 trainers conducted 746 health sessions in seven months running 141 clubs with 10,620 members, the project cost amounted to 43c (US$) per beneficiary. With the latest study of PHAST in Uganda estimated from US$16-24 per beneficiary, the Zimbabwe experience should be revisited. With such immense investment in PHAST in the past ten years it would be wasteful to abandon the approach – rather it needs to more structured. The recommendation of this article, based on empirical evidence is this: situate PHAST within a Health Club structure and it will provide cost effective behaviour change. (Waterkeyn & Cairncross, 2004)

2004. Social Capital Conference, Rhodes. Waterkeyn, J. The Need for Knowledge: Maslow’s Hierarchy of Needs applied to rural communities in Africa.

Abstract: Although literacy rates in developing countries have improved substantially in the past few decades, vertical health promotion programmes for rural communities still tend to pitch their messages at a low comprehension level, promoting only a few simple key messages usually to prevent only one identified disease (Loevinsohn, 1990). The overall literacy level in Zimbabwe is around 86% (Unicef, 1999) although 50% of those over 60 are illiterate (Auret, 1990). A recent study in Zimbabwe (Waterkeyn and Cairncross, 2005) has piloted an approach using Community Health Clubs to promote a culture of health by improving health knowledge and hygiene behaviour. Interviews with members indicated that the popularity of Health Clubs was largely due to a strong interest in acquiring knowledge. Consistently high attendance rates suggested that women were prepared to invest considerable effort to learn. A post intervention survey found that good knowledge of Malaria amongst health club members was 34% higher than non-members, and for Tuberculosis it was 58% higher (Waterkeyn, 2006). Taking an average of nine different topics, there was 47% difference between intervention and control areas (0>0.0001). Maslow’s Hierarchy of Needs (1954) was used to categorise suggestions from the community as to their main needs, using a method of pair-wise ranking on a matrix. In a random sample of ten community health clubs, 20% voted their highest priority as Knowledge, whilst the remaining 80% ranked Knowledge in second place, only slightly less important than their Need for Safety. These findings indicate that semi-literate communities have the capacity to assimilate multiple messages and through group decision-making can significantly change their hygiene behaviour, acting on a broad range of health issues. By addressing all preventable diseases in a more holistic approach to health, programmes would be more cost-effective and appropriate to the needs of rural communities.

2003 29th WEDC. Abuja Waterkeyn, J. Cost Effective Health Promotion: Community Health Clubs.

Abstract: The new strategy of using Community Health Clubs as a vehicle for rural health promotion was first used in Zimbabwe, in 1994 in Makoni District, in a field trial initiated by the author. As the demand for expansion increased, an NGO, Zimbabwe A.H.E.A.D. (Applied Health Education and Development) was founded in 1997 to support Ministry of Health implement this new approach, in the three districts of Makoni, Gutu and Tsholotsho. The training of community takes place once a week for six months, with at least 20 sessions being conducted on different topics. The methodology used in the AHEAD Approach recognised that Health Promotion is the ideal entry point for development. It maintains that if this is used as a process to develop a real ‘common unity’ of understanding and a ‘culture of health’ within a community, subsequent W & S programmes will be effective, easier to implement, and sustainable. The objective of this paper is to demonstrate the low costs of effective health promotion (using the AHEAD Approach) to the donor, in an effort to encourage greater investment in this essential component of a Water and Sanitation programme. Costs of the field staff conducting the Health Promotion are calculated to give a cost per beneficiary. Additional Costs not included are US$ 47,709 (40%) for Sanitation (3128 VIP latrines in two years); US$ 36,878 (30%) for establishing over 500 income generating projects, as well as US$ 10,242 (10%) on Administration. The Total Project cost for 2000 was US$120,000, of which only 20% was spent on Health Promotion. In the second year, cost per beneficiary dropped from 0.91 in Year 1, to only 0.35c. This token amount can improve health knowledge of the mother, which can result in upgrading of family hygiene and the prevention of many diseases. When this budget is recalculated as a cost per trainer, (including training, equipment, motorbike and running costs), this amounts to only US$3,144 for two years.

2002 World Bank publication Sidibe, M. & Curtis, V. Hygiene Promotion in Burkina Faso and Zimbabwe: New Approaches to Behaviour Change. Blue-Gold Field Note, Water and Sanitation Program. WSP-Africa Region, World Bank.

Abstract: After years of debate, most people working in water and sanitation now agree that hygiene promotion is vitally important. But even now, many programmes and projects either ignore it or do it badlyThis Field Note describes two African hygiene promotion programmes that have successfully used new approaches: Programme Saniya in Burkina Faso, and ZimAHEAD in Zimbabwe. They have both concentrated on understanding how people actually behave and hence how to change that behaviour. One of them (Programme Saniya) was comparatively small in scale but demonstrated ideas that can be applied at a larger scale. Changing human hygiene behaviour is a long process that is difficult to measure, and both of these programmes still have obstacles to overcome. However, this work indicates that systematic and carefully managed hygiene promotion programmes can achieve improvements in hygiene behaviour and hence reduction in diarrhoeal diseases.

2000. 26th WEDC Conference. Dhaka Waterkeyn, A. & Waterkeyn, J. Demand Led Sanitation in Zimbabwe.http://wedc.lboro.ac.uk/resources/conference/26/Waterkeyn.pdf

Abstract: Whilst many sanitation projects have struggled to interest their beneficiaries in the positive advantages of latrines, By contrast, Zimbabwe A.H.E.A.D. projects are battling to keep up with the demand for latrines from the communities.This paper explores a methodology that works to develop a “Culture of Cleanliness” through the establishment of Community Health Clubs. Rather than starting immediately with the implementation of a water and sanitation programme, health education is used as the first point of entry into the project area. By the end of six months of health promotion, the move to improve home hygiene comes naturally to Health Club Members, who readily contribute towards upgrading their own sanitation. In Matabeleland North Province of Zimbabwe, the technical problems of constructing latrines in collapsing Kalahari sands have made latrines expensive to construct and consequently sanitation coverage is often below 10%. To solve this problem, a technology has been devised that enables women to make interlocking bricks and line their own pits. Whilst the main cost is below ground, the superstructure is constructed cheaply with local materials, resulting in culturally appropriate and therefore sustainable structures.

1999. 25th WEDC Conference. Addis Ababa. Waterkeyn, J. Structured Participation in Community Health Clubs http://wedc.lboro.ac.uk/resources/conference/25/119.pdf

Abstract: This was the very first paper written on what was then a new methodology. It analyses the Community Health Club from a social perspective, demonstrating how and why clubs are formed. It also explores the reasons for the popularity of the clubs and looks at the social psychology that is asumed to motivate people behind this innovative approach.

POSTERS

2002: Poster: Royal Society of Tropical Medicine and Hygiene. Waterkeyn, J. Quantifying the Cost-effectiveness of the Community Health Club Strategy in the Rural Areas of Zimbabwe: An Intervention Study: Tsholotsho District, Matebeland North

Prize for the best PhD Research in Process

Abstract: This Intervention Study forms part of a larger report of a Health Education, Water and Sanitation Programme that took place in three Districts of Zimbabwe between 1997 and 2000. Between the three areas approximately 500 Community Health Clubs were established of which 32 were formed in Tsholotsho. Although it was the smallest and the most underdeveloped of the three areas, it was in this District that the community responded to the Health Clubs most vigorously and indicators of behaviour change were exceptionally high. The research was conducted in the second year of the project and the findings show a high demand for sanitation and strong adherence to recommended hygiene practices. At the time of the survey 70% of the Members had attended 20 or more health education sessions held weekly in the programme. Whilst sanitation is traditionally resisted by rural communities this project was able to demonstrate an almost unanimous uptake of improvements amongst Health Club members, with 57% constructing latrines by the second year; the remainder using the “cat sanitation” method of burying their faeces with a hoe, as an interim measure until the project could meet the demand. The recommended practices for improved hygiene do not involve much extra expenditure on the part of the members, except for the major investment of building a latrine. In this project the members contributed 60% of the cost of construction in terms of materials and labour, whilst three bags of cement were donated at a cost to the project of US$15 per latrine. The cost of health education is calculated by the expenditure on the initial training of the Government trainer and provision of a motorbike which together cost US$2,666, as well as monthly allowances and running costs of a motor bike which amounted to approximately US$850 per month. Thus a total cost, including capital outlay for the first year would be US$12,866 per trainer. In Tsholotsho (1999) the cost of Health Education training was US$38,598 for 3 trainers. If this is divided by 11,577 beneficiaries (2105 families of 5.5 members each) it amounts to only US$ 3.33 per beneficiary. This excludes the cost of the NGO’s project officer, which may not always be required in areas with entire implementation by the Government.

2009: South Africa, Rural Kwa Zulu Natal Jason Rosenfeld: This Poster is a visual summary of the Danida funded IWRM project in South Africa, where 10 CHCs achieved high levels of behaviour change within an 8 month period in one of the poorest areas of Kwa Zulu Natal.

2010: South Africa, eThekwini Durban, Natal informal Settlement Nancy Maksimoski:

This poster is a visual summary of a 6 month pilot project in Johanna Road Informal Settlement, outside Durban, and shows the level of hygiene behavior change in one Community Health Club.

2008: PHASA. Herbs Can Help Dr. Juliet Waterkeyn & Josephine Mutandiro

Abstract: With the terrible effects of the HIV/AIDS pandemic, medical services in rural areas of many developing countries cannot keep up with the demand for treatment. Where ARV and other drugs are scarce, herbal remedies can provide ‘first aid’ and alleviate the many uncomfortable symptoms of opportunistic disease associated with HIV/AIDS. In the past five years an innovative herb programme has been introduced to over 4000 households through Community Health Clubs in Zimbabwe, and people living with AIDS have been trained in the growing and use of herbs in nutrition gardens. Based on well-reputed research (Bartram, 1995) the poster presents 30 of the most useful herbs used in this programme. The information is presented in the form of a user-friendly matrix, developed specifically for the use of rural semi-literate communities. It enables those who are growing the herbs to have a ready reference, to ensure the correct herbs are used. Ailments can be treated with the right herbs by identifying the appropriate symbol on the x axis, (representing areas of the body where symptoms occur), and then following the column down to see which herb is marked for use as an effective remedy. Numbered illustrations of each herb on the y axis are related to photos of each herb around the border. A booklet is being printed for the facilitators in each community with more detail on growing and using herbs. The poster was pretested in a recent training which confirmed that even semi-literate women with little English can access this information accurately. Furthermore, it has now been shown that villagers can be trained to treat symptoms without formal medical diagnosis of disease. Herbal remedies can provide a self-help solution in rural areas where long distances to clinics, lack of transport or funds, prevent medical treatment.

COUNTRY REPORTS

2011 Vietnam Evaluation of the Community Health Club Pilot Project 2009-2010

2010 ZIMBABWE AHEAD ANNUAL REPORT

For full 2010 Annual Report

Regis Matimati, Director of Programmes

ZimAHEAD team was at it again in 2010 scoring major public health goals with outstanding achievements in all our programming areas. The EC funded project in partnership with Mercy Corps drew to an end in October 2010 after three years of building community capacity to address health and nutrition in Buhera, Chipinge and Chiredzi. All project targets were exceeded at no extra cost. (See Annual Report, page 9)

In partnership with Oxfam on an OFDA funded project, we burst into national limelight which resulted into phenomenal hardware outputs, thanks to our Programme Manager, Andrew Muringaniza. After only six months of software promotion, the Chiredzi community, constructed over 235 top of the range latrines and thousands other health and hygiene enabling facilities with zero subsidies. Two Directors from Ministry of Health, from the Department of Environmental Health, and the Department of Infrastructure Development, toured the area and were spell bound by what they saw. Even the National Coordination Unit’s Coordinator was surprised by what the communities did with stimulation from ZimAHEAD in Chiredzi and Masvingo urban. Communities took control, showing accountability, ownership and responsibility over their own health and development spurred by the motivation in the health club sessions. (See Annual Report, page 10)

In particular the Garikai community attracted attention. Once they were the black spot of Masvingo town looked down upon by other residents of Masvingo. Their place is now a symbol of health after they joined the clubs and cleaned their area, they are now proud of their homes and walk with heads held high, a big difference from the past. (See page 11). ADRA and ACF contracted us to offer them training and backstopping support and this was done to satisfaction, training their teams in Gokwe North and Matabeleland South.

Association for Applied Health Education And Development

Project Areas