2009.KZN poster.pdf

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PROJECTS UNDERTAKEN IN SOUTH AFRICA

1. Development of generic CHC Training manual and extensive PHAST Tool Kit for Informal Settlements (City Health Department- Danida)

2. Training for City Health Department of facilitators to start CHCs in Informal Settlements near Cape Town

3. Support to Hygiene Promotion Partnership for base line survey to ascertain level of hygiene behaviour change in 4 informal settlements

4. Feasibility study for Integrated Water Resource Management (IWRM)to start CHCs in 3 water catchment areas in South Africa ( DWAF-Danida)

5. Planning and implementation of a comprehensive CHC programme in the rural areas of Kwa Zulu Natal for DWAF-IWRM (See Map: A)

6. Training of 25 Sangoco facilitators to start CHCs in North West province (Sangoco NGOs- DWAF-Danida) (See Map: B)

7. Training of Water and Sanitation Forum facilitators to start health clubs in Khayelitsha (for University of Western Cape)

8. Planning and implementation of a pilot CHC project in eThikweni (Durban) informal settlement

1.PHAST Manual and Tool Kit to enable scaling up of training

In 2008 Africa AHEAD, in conjunction with the City Health Department, developed and published a dedicated manual

Community Health Clubs in Informal Settlements: A training manual for community workers using participatory activities. Developed by J. Waterkeyn for City of Cape Town Health Department. Funded by Danida. Illustration by Itayi Njagu.

This manual comes with a comprehensive PHAST Tool Kit for informal Settlements consisting of 13 essential topics related to home hygiene.

The training comprises of three Modules:

Module 1: Feasibility: the Rationale for the Community Health Club Approach

A one day training for Managers and decision makers to enable them to visualise and understand the reason for ‘doind development’ through Community Health Clubs)

Module 2: Planning: How to start a Community Health Club Project:

A three day training for middle management and supervisors as well as the facilitators of the CHCs.

Module 3: PHAST Participatory Activities for Informal Settlements

A six day training for facilitators only to enable them to use all the PHAST toools and carry out 24 training sessions with community Health cubs

Please contact juliet@africaahead.com for more information if you are interested in this training.

2. City Health Department Pilot Community Health Clubs in the Cape Flats

2008. Belleville Cape Town: the first CHC facilitators to be trained

The first batch of trainees were passed after a six day workshop in March 2008, and are expected each to start one health club. Although the xenophobic riot of 2008 affected the start up of health clubs in many areas there is at least one success story in Phillippi. There are over 200 members in three health clubs and their training is providing an inspiration to replicate the project in other areas. In the near future all the CHCs will be assessed by Africa AHEAD with a view to learning lessons as to how the health clubs are being received in the Cape Flats. It appears that there have been several challenges including the difficulty of the members to meet during the xenophobic unrest that swept the informal settlements in South Africa last year. there are also concerns as to how the health club facilitators were supported and if there was enough supervision by Environmental health Personel to ensure that the sessions were heald as planned in the workshop.

Another training is to due to be hele in April / May supported by the Health Department , when the next intake of community members will be trained by Africa AHEAD to start Community Health Clubs in different areas.

3. Feasibility Study for Integrated Water Resource Management

In 2000, the South African Department of Water Affairs and Forestry (DWAF), with the assistance of the Royal Danish Government (DANIDA), initiated a program to pilot Integrated Water Resource and Management (IWRM) approaches in three Water Management Areas (WMA) of South Africa: the Olifants-Doorn (Western Cape Province), the Crocodile-Marico (North West Province), and the Mzimkhulu-Mvoti (Kwa-Zulu Natal Province). These WMAs were selected as they represent a cross-section of water resources conditions as well as water use conditions and user interests. Phase 2 of this project, which focuses more on direct support and partnerships at local, regional and national levels, was begun in 2006 and is set to last until 2010. For more information about IWRM activities in South Africa, please visit www.iwrm.co.za.

The CHC Approach will contribute to the goals of IWRM by building a strong foundation of knowledge, cooperation and behavior change in each of the targeted communities. This foundation will then be used to successfully implement a variety of projects such as rain water harvesting, nutrition gardening, income generation, HIV/AIDS case management, and improved management of sanitation facilities.

In May 2008, Africa AHEAD was invited to assess the feasibility of piloting Community Health Clubs (CHC) in targeted areas within the three WMAs. Between May and September 2008, stakeholders were engaged, situational analyses and site visits were conducted, and project proposals and plans were submitted.

4. Community Health Club Pilot Project in Umzimkhulu: Kwa Zulu Natal

Participants in a Health Club Training Workshop in Umzimkhulu - Jan 2009

The team: Project Officer Moses, Council Representative Tabiso and Jason Project Manager for Africa AHEAD in Umzimkhulu

Africa AHEAD has been contracted to implement a pilot project in the Mzimkhulu-Mvoti WMA, within the Umzimkhulu Municipality. Umzimkhulu which is located in the foothills of the Southern Drakensberg Mountains. Until recently Umzimkhulu was a part of the Eastern Cape Province, and as a result the levels of development in this district are far below the standards found in the rest of the Kwa Zulu Natal. According to the Municipality’s 2008 Integrated Development Plan, 40.2% of the population has access to piped water sources, with the remainder using unprotected sources such as rivers, streams and springs. In addition, while 92.9% of households reportedly have access to sanitation facilities, the majority of these facilities are neither safe nor hygienic. This low level of development is ideal territory to start a community health club programme as past research has shown.

The project in Umzimkhulu began to take shape from Septemeber 2008, as the Municipal Council approved the implementation of CHCs in all 18 Wards, a Project Steering Committee was constituted, the sites for implementation were selected and Africa AHEAD welcomed its newest team member, Mr. Moses Mncwabe, Project Officer for the Umzimkhulu project. The site selection process was a competitive one, with interested Ward Councilors submitting an application form indicating the communities they wanted to participate and the names of potential facilitators to be trained by Africa AHEAD. 10 Councilors who submitted applications, to join the programme and the Project Steering Committee selected one community and facilitators from each ward. Community Health Clubs have now formed up and facilitators have been trained in base line research. the base line survey was completed in January 2009, and the PHAST training is to be started in mid February, and continue every second week. Facilitators will then rely the training back to their ward where their health clubs will meet every week. The training will be complete with six months, by the end of August 2009.

5. Replicating through local NGOs: North West Province

Africa AHEAD is working closely with the South African National Non-Governmental Organization Coalition (SANGOCO) to start up CHCs through training the staff of existing local NGO’s in the North West Province and Gauteng. Unlike other projects which are implemented directly by Africa AHEAD, the input in this project is merely to train and mentor the staff of 3 local NGO’s, who will then manage the implementation and activities of CHCs in their catchment areas. While most of the CHCs in this WMA will be formed in communities in and around Mafikeng and Zeerust (North West Province), there is one Community Based Organization in Majaneng (Gauteng Province), near Hammanskraal, that will also be implementing CHCs.

NORTH WEST PROVINCE: Africa AHEAD will be collaborating with SANGOCO and two NGO’s based in the North West Province to implement CHCs, Tlhoafalo Advice Center and Lethabo Water and Sanitation. Each NGO will have between 7-9 staff trained in the CHC Approach by Africa AHEAD and will develop CHCs in 5-6 communities.

GAUTENG PROVINCE: Majaneng is a small rural settlement located on the border of the Gauteng and North West Provinces. In this area, Africa AHEAD will again be collaborating with SANGOCO and one local Community Based Organization, the Kekanastad Traditional Mothers Organization (KETRAMODEO). Africa AHEAD will train 5 members of this organization who will then develop CHCs in 5 sub-areas of Majaneng.

A three day training workshop was held from 11th-13th August 2008, on Module 2: How to start up Community Health Clubs. At this training the NGO staff were given activities to help map and analyse the areas to prioritise within their areas of operation. They were also trained to carry out a base line survey of 100 household in the selected area. This was done through the innovative method of using ordinary cells phones to capture data in the field. (See Publications, Rosenfeld and Waterken, 2008). The data is then automatically collated and preliminary result have been collected and a report issued by Africa AHEAD who are to process the data and provide on going support to enable any behaviour change to be measured effectively. The CHCs have now been formed up, the base line data collected and facilitators from the NGOs are now waiting for the next phase of the training which is being delayed by funding constraints. Local NGO are begging to start the next training as their communities have been mobilised and are loosing interest with such delay.

6. Hygiene Promotion Partnership Research

Brigham Young University, (on behalf of Rickett Benkisser) started a research programme in four informal settlements to establish whether the use of antiseptic cleaning material in home could reduce diarrhoea in low income homes. In order to conduct this research an intervention was planned to monitor 140 clusters in four informal settlements: Phillipi, Du Noon, Kwa 5, and Sweet Home. The model was that each of the 65 facilitators would hold weekly sessions in a cluster of ten homes. As the strategy was very similar to the CHC approach, Africa AHEAD was called on to help develop the training materials for the modules which were prepared by HPP. The beneficiaries of the programme were able to assist in the development of the PHAST Tool Kit and HPP supported the development of the illustrations, and HPP trainers were trained by Africa AHEAD to use the materials. Although this programme has now been completed, many clusters have become viable grass roots groups and anecdotal evidence is strong that they have improved in their home hygiene practices.

Participants learn how to make a squezzy bottle: a practical solution to handwashing outside informal shacks

New Research Findings on Behaviour Change

PUBLICATION:

Comprehensive Family Hygiene Promotion in Peri-urban Cape Town: Gastrointestinal and Skin Disease Reduction in Children Under Five. Cole, E, Hawkley, et al. Brigham Young University.

‘Community based PLA proved to be a powerful approach for reducing illness through supporting families in the adoption of new hygiene practices and in mobilising the communities for health and social change.

Achievements of facilitators and study participants included the health and hygiene situation in households and neighborhoods, setting up of hand-washing stations, teaching children and neighbors correct hand washing methods, instituting child safety practices, influencing vendors to practice hygienic food preparations, managing communal toilet and rubbish pick ups and determining how to link health to local economic development.’

Reduction in disease
Findings from this paper indicate that Skin infections were reduced by 39.1% in formal housing but interestingly not in informal housing.

Gastroinstestinal infections were reduced by 14% in formal housing and by 11% in informal housing.

7. University of the Western Cape – Khayelitsha Sanitation Forum

The concept of Community Health Clubs was first floated in South Africa in 2005, supported by the University of the Western Cape, in a pilot project in Khayelitsha, one of the most challenging informal settlements in the Cape Flats. 25 Facilitators were nominated by the Khayelitsha Sanitation Forum, and training was provided by Africa AHEAD. Due to insufficient support most of the health clubs never took off, but one determined facilitator has shown that CHCs in informal settlements can play an important role in providing support to the needy.

Saviour Maqaloti : The first facilitator to start a Community Health Club in the Cape Flats

Philisanani Community Health Club

One of the facilitators, Saviour ran with the idea and mobilised a huge following of over one hundred members. trained the group over the next six months and Africa AHEAD was delighted to be able to provide certificates for the 25 core members who had completed every session. Some of the group have become voluntary clinical assistants, while another has started a play school and yet another has a voluntary service assisting the pensioners access their pensions and ensure they are properly cared for. The group has become a registered CBO called Philisanani and has recently secured government funding for a second training in home hygiene for which Africa AHEAD is providing certification.

]]> http://www.africaahead.org/south-africa/18/01/2010/feed/ 1 http://www.africaahead.org/hygiene-behaviour-change-monitored-in-umzimkhulu/18/01/2010/ http://www.africaahead.org/hygiene-behaviour-change-monitored-in-umzimkhulu/18/01/2010/#comments Mon, 18 Jan 2010 06:40:57 +0000 africaahead http://www.africaahead.org/?p=1051 Umzimkhulu Municipality in Sisonke District of KZN was selected by the Department of Water Affairs to pilot this project that was initiated as part of the IWRM (Integrated Water Resource Management) programme being funded by the Danish Embassy (DANIDA). Umzimkhulu was part of the Eastern Cape until it was recently absorbed into [...]]]> BACKGROUND

Umzimkhulu Municipality in Sisonke District of KZN was selected by the Department of Water Affairs to pilot this project that was initiated as part of the IWRM (Integrated Water Resource Management) programme being funded by the Danish Embassy (DANIDA). Umzimkhulu was part of the Eastern Cape until it was recently absorbed into Kwa Zulu Natal. The area has one of the lowest levels of development in KZN as demonstrated in this base-line survey which highlights that safe drinking water supply is a major challenge with only 15% of households having access to a safe water source whilst the remaining households have to use open ground water, usually in the form of unprotected springs. As this surface water is open to contamination it needs to be treated or boiled before consumption. Sanitation usually consists of a household pit latrine and although the coverage is high at 90%, around 50% are unhygienic, smell and attracted flies which would account for the high levels of diarrhoea in the area. Most social scientists would agree that changing people’s hygiene habits is notoriously difficult, and there are few good case studies to-date. Africa AHEAD was commissioned as service provider to introduce a health promotion campaign in the 1st phase of an holistic development package that would build the capacity of the community through health clubs, with the objective of developing a community-led demand for improved water and sanitation. Although Africa AHEAD has initiated Community Health Clubs in informal settlements, this is the first pilot project in South Africa to be implemented in a rural community.

THE COMMUNITY HEALTH CLUB APPROACH

It has been shown in a review of over 100 studies that Health Promotion alone can reduce diarrhoea by 33%, while hygiene changes such as ensuring safe drinking water can diminish diarrhoea by 15%, safe sanitation by 35%, and safe handwashing with soap by 47% (Esrey, 1991). As the Community Health Clubealth promotion campaign in nine wards of Umzimkhulu. In February 2009, worki
Approach is known to be capable of achieving high levels of behaviour change (Waterkeyn & Cairncross, 2006) it was chosen as the strategy for a hng with the Umzimkhulu Municipality and local councillors, a Community Health Club was started in each ward. Africa AHEAD trained facilitators from the community in how to conduct health promotion sessions using PHAST participatory activities to promote hygiene behaviour change. Almost 1,000 members were registered and weekly sessions were held in all nine wards. Attendance rates varied according to the proficiency of the facilitator, but although most members attended some sessions, there were 550 hard-core members who completed all 24 health topics within six months. Certificates were awarded at a Graduation Ceremony in September 2009, attended by district and provincial representatives which marked the end of the pilot project. In the next phase, relevant government departments are planning to use these well mobilised communities to improve water, sanitation and quality of life through agricultural and income generating activities.

RESULTS

The levels of behaviour change as a result of this project are exciting, with an overall average of 20%. In the post intervention survey (September 2009), it was found that 76% of all registered members are now following the recommended practices promoted during the weekly health promotion sessions. Whereas before the project only 18.1% had safe water, there is an 41% change. Although the water source is still not safe, 51% now treat their water,86.1% store it safely and 87% take it using a ladle, so minimizing contamination. Sanitation has improved by 14%, from 71.1% with no open defecation to 87.8% of members having ZOD (Zero Open Defecation) defined as clean covered latrines with no faeces. In addition, whereas only 29% of member households had dedicated hand washing facility near their latrine at the beginning of the project, 70.1% have now constructed a simple facility that allows them to wash their hands immediately upon exiting their latrine. Even more impressive is the use of soap for hand washing that has risen from 40.1% in February to 68.4% six months later. An observable indicator is an 18% drop in Ringworm seen in CHC households, a disease caused by infrequent washing and lack of soap, 87.7% mother can now prepare SSS correctly, so saving babies that might have died from dehydration. There is little doubt that family health has been improved where health clubs have been established in Umzimkhulu, and demand to scale up this programme to all other wards is high. Meanwhile the self-motivated improvements that some HealthClubs have already made contingency measures to protect their water sources.without any external financial or technical assistance. Each CHC now has a trained building group, now constructing safe latrines on demand for members. This display of self reliance validates the CHC Approach, which aims to empower communities so that they manage their own health and utilize existing resources more effectively, at least until government can provide the required services.

RESEARCH METHODOLOGY

METHOD

Study Type: Intervention Study
Sampling: Purposeful
Technology: Mobile Research Platform
Enumerators: Seven local CHC facilitators
Health Clubs: Seven
Total Membership: 1000
Hard Core membership: 550
Sample Size Baseline: 469
Sample Size Post Intervention: 538

Demography of the CHC Respondents

Total Female Male
Total Number of Respondents 251 311 60
Median Age 40 38.5 39.2
Married 45% 45% 45%
Single 22% 50% 36%
Widowed 24% 3% 13%
Household size 5 4 4.5
Christian Denomination 46% 48% 47%
Christian Apostolic 53% 43% 48%
Traditional Religion 0.4% 5% 2.7%
Education & employment
No schooling 7% 4% 5%
Primary only 37% 33% 35%
Secondary 38% 35% 36%
Matric + passed 18% 28% 23%
Unemployed with Matric + 70% 56% 63%
No formal income 51% 58% 54%

Prior to the training a base line survey was conducted in all nine wards, with most Community Health Club members being interviewed. Each month, this ‘household inventory’ was redone, and hygiene changes as represented by the 12 observations in household inventory were tracked by the community facilitators. There are more respondents in the post intervention as members increased. Two of the facilitators failed to complete the surveys correctly and the data was rejected. Although preliminary finding in were higher in Round 5, (August 2009) the data in this poster shows the final round 6 data using only 7 out of 9 CHCs to ensure correct claims (September 2009). One observation ‘pour to waste’ hand-washing method was ignored as it was obsolete when members adopted the hand washing facility which was a more reliable indicator , being more observable.

TECHNOLOGY

Most household surveys are conducted on paper, and this leads to much human error and spoilt forms. To speed up data collection and collation and minimize human error, an innovative tool has been used in this research. A standard mobile phone was issued to each facilitator with the Household Inventory installed. Responses could be keyed eliminating human error, and data sent like an sms to a central website where results were updated automatically and instantaneously. This eliminated manual computer entry, and thus much time and error was saved. The monthly monitoring with cell
phones gave facilitators a more glamorous role, and the members responded to this monitoring (Hawthorne Effect) by making changes
that were recommended. Thus the monitoring has contributed as much as the methodology to the high rates of behaviour change.

Observed Home Hygiene changes before and after 6 months of weekly health promotion training sessions

Baseline Post Increase
Treated Drinking Water 18.1 59.3 41
Use of a Ladle 73.3 87.7 14
Safe Water Storage 78 86.1 8
Safe Food Storage 79.7 92.4 13
Use of Pot Rack 72.1 89.4 17
Zero Open Defecation 71.1 84.8 14
Hand Wash Facility 29 70.1 41
Use of Soap 40.9 68.4 28
Use of Rubbish Pit 74.2 86.6 12
No Ringworm 72.3 89.6 17
Make SSS 69.3 87.7 18

Average Increase in behaviour change 20%

Recommended Practices p>0.001

Active Members of CHCs

Baseline n=469 Post Intervention n=538

Purposeful sample of 3 wards

Demography of the CHC Respondents

CONCLUSION

• The hygiene practices of Community Health Club members have been significantly improved as a result of the health and hygiene promotion using the CHC approach.

• There is a high demand for safe sanitation (Ventilated Improved Pit latrines) & safe water sources (protected springs)

• As the faecal-oral transmission route has been broken in all CHC areas by safe water, food, sanitation (Zero Open Defecation), and hand washing with soap, diarrhoea should be effectively minimised in Umzimkhulu.

The base line survey has been completed for Umzimkhulu and provides some guidelines as to the most pressing gaps in health knowledge that can be filled and hygiene behavior that can be changed by the Community Health Clubs. Based upon the results of this report, and given that the three selected villages are representatives of the whole of Umzimkhulu, it would appear that the CHC Approach can make significant differences in the lives of the participating communities. The three selected villages represent a high, medium and lower living standard and it is reasonable to assume that the rest of the district will fall somewhere in between. It would also appear that the topics to be done in health promotion sessions are indeed appropriate for the target communities, and that the training can proceed without alteration to the training materials. If the 24 health sessions are completed as planned we can expect that there will be significant improvement in health knowledge and behavior, and would predict an average of between 20-30% change in most hygiene behaviours.

The training intends to focus on water usage and storage, safe disposal of human faeces and solid waste, as well as diseases that can be prevented by poor hygiene such as diarrhoea, scabies, ringworm, and intestinal worms. This report highlights that there is indeed room for improvement in all these areas. 80% of the households that were surveyed in the three villages still use unprotected water, and 51% have dirty latrines, 60% had a fly problem in kitchens of with only 43% of those with left over food making any to protect food from flies. 55% of households reported rats were a problem and with 74% reporting a rubbish problem and with 54% of households having solid waste within close proximity, these are areas that can be improved significantly. Handwashing probably provides the best opportunity to impact on the prevalence of diarrhea as only 8% households use soap regularly. As regards levels of health knowledge there is little doubt that the programme will register a significant rise in good health knowledge from the average of 18.6% for the six topics which were asked.

It is also clear that the district of Umzimkhulu is an ideal area for a pilot project as the level of safe water supply, sanitation and general hygiene is decidedly low as compared to more developed areas in Kwa Zulu Natal. This low base line will enable a clear measurement of impact using the proxy indicators that have been carefully linked to the training and the recommended practices which are expected to be put into place within the next six months. Given the current low provision of safe water supply and adequate sanitation, this base line report should to circulated to service providers of water and sanitation to alert the relevant authorities that within a few months there will be a sudden demand as a result of this training programme, and that planning to deal with this demand should be already in place to ensure a seamless transition from demand creation to improved living conditions in Umzimkhulu.

Now that the base line survey is complete, the Community Health club training will start in 10 wards. the facilitators have been selected from the community and are being trained in bi-weekly sessions. They have already mobilised their communities and initial response is very encouraging. There are estimated to be an average of 75 members per club and one club has even exceeded 150 people all looking forward to the future training. Most facilitators have already done five sessions and will be finished within another five months.

Start up has been delayed by two months due to slow uptake by some councillors but reports are now coming in that the councillors are excited about the initial activities and those that were slow to apply for the project are now regretting the fact that they missed the deadline. At present this project is supported by Danida and IWRM until June 2009 through the Department for Water Affairs and Forrestry but given the demand there is likely to be a viable programme in Umzimkhulu for many years to come and support is being sought for the scaling up of this novel approach that holds such promise for the poorer areas of KwaZulu-Natal.