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.  Inspite of much sceptism that nothing could be done to aleviate 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!

Uganda IDP Case Study

January 20th, 2010 | Tags: Case Study, Community Health, Health Clubs, Latrines, Northern Uganda, UGANDA | Category: Download PDFs, Health Promotion, UGANDA | Leave a comment

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COMMUNITY HEALTH CLUB PROJECTS

1. CARE International (funded by Gates Foundation)

In 2003, Africa AHEAD provided training for 23 facilitators from HIDO, a local NGO and a PHAST Toolkit was developed specifically for the IDP Camps. Trainers were then posted into 15 Internally Displaced People’s camps in Gulu District. Within a month over 116 Community Health Clubs with over 15,000 members, had been registered and weekly sessions were held for six months. By this time over 11,256 latrines, as well as 11,709 pot racks, and 2127 hand washing facilities had been constructed. This record breaking number of latrines highlights the power of the CHC Approach to create a strong demand for sanitation even crowded IDP camps, in an emergency setting within a short period of time.

2. Malaria Consortium – HIDO (funded by Unicef):

The approach was then taken to Pader District, also a refugee area in Norther Uganda, by HIDO (in partnership with Malaria Consortium). Another 35 health clubs were established with 2,599 members in 8 IDP camps and within 5 months 51% (1,318 members) had built latrines as well constructed 400 rubbish pits, 1,644 pot racks and 810 bathrooms.

3. Lutheran World Federation:

Based on recommendations in an evaluation (by Cranfield University), Community Health Clubs were started in Katakwi by Lutheran World Federation. In October 2006, a local EHD trainer who had co-facilitated with Africa AHEAD in the Gulu Trainer successfuly trained LWF field staff in PHAST and the CHC approach. By March 2007 there was a 40% uptake of sanitation. This was important as it shows how replication does not depend solely on Africa AHEAD, and points the way forward as to how Uganda can scale up CHCs without external consultancy.

4. WaterAid and partner NGOs pilot CHCs:

In May 2008, Africa AHEAD provided training for WaterAid local partners to enable them to start up Community Health Clubs in various areas of Uganda: Busoga Trust in Southern Uganda, whilst SSWARS and AEE operate mainly in Kampala. WEDA, another highly successful implementing partner is currently conducting a successful program in Katakwi using Clusters rather than health clubs and will be integrating some of the CHC ideas into their home grown health promotion methodology.We await an update on how these organisation have adapted the CHC Approach to their own contexts.

Accredited CHC Trainer: Justin Otai (MoH); Victor Kwame (HIDO)

Africa AHEAD Consultant: Dr. Juliet Waterkeyn

PRACTISING ORGANISATIONS:

CARE International; HealthIntegrated Organisation for Development (HIDO); Malaria Consortium, Unicef; WaterAid; UWASNET, Lutheran World Federation; WEDA; SSWARS; AEE; Busoga Trust

TRAINING MATERIAL: MoH PHAST Training Manual (available in country from EHD-MoH)

REPORTS: Waterkeyn. J. (2008) Africa AHEAD Scoping Study: Community Health Clubs in Uganda. Part 1. WaterAid Uganda.

PUBLICATIONS

UWASNET: Uganda Water and Sanitation NGO Network, Members Directory 2007-8

UWASNET. Group Performance Report for 2007.

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

Mpalanyi.J. and Mukama.D. (2007) Documentation of best practices (BOP) in hygiene and sanitation in districts of Uganda. WSP – AF.

Hygiene & Sanitation Strategies in Uganda: How to Achieve Sustainable Behavior Change?

Waterkeyn, A. (2005). Hygiene & sanitation strategies in Uganda: How to achieve sustainable behaviour change? Kampala, 31st WEDC Conference.

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.

For full article in pdf, click here: Hygiene and Sanitation Strategies in Uganda: How to Achieve Sustainable Behavior Change

January 18th, 2010 | Tags: Health Clubs, HIDO, Hygiene Behaviour & Practices, IDP Camps, Latrines, Malaria, PHAST, Training Materials | Category: Countries, UGANDA | Leave a comment

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.

January 18th, 2010 | Tags: Baseline Data, Danida, Diarrhoeal Diseases, Health Clubs, Health Promotion, Integrated Water Resource Management, KwaZulu-Natal, Latrines, Participatory Activities, PHAST, Pilot Projects, Rural Areas, Skin Diseases, Solid Waste Disposal, Water And Sanitation, Water Sources, Women | Category: Countries, KwaZulu-Natal, SOUTH AFRICA | Leave a comment

March 2009. J. Rosenfeld & J. Waterkeyn

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.

January 18th, 2010 | Tags: Danida, Diarrhoeal Diseases, DWAF, Hand Washing, Hygiene Behaviour & Practices, Integrated Water Resource Management, Latrines, Pilot Projects, Rural Areas, Skin Diseases, Solid Waste Disposal, Water Storage, Water Usage | Category: Countries, KwaZulu-Natal, SOUTH AFRICA | Leave a comment

The Directors of Africa AHEAD, Juliet and Anthony Waterkeyn have recently been on a combined consultancy to Bhutan at the request of SNV, which is the leading development agency supporting Government in this extraordinary hidden Himalayan Kingdom.

The objects of the consultancy were twofold:

1. Anthony to assist in developing an appropriate design for Bhutanese sanitation;

2. Juliet to design a base line survey for measuring the effectiveness of the future two year health promotion programme.

BASE LINE SURVEY OF HOME HYGIENE

The survey took place in the southern Geog (District) of Nangong, a two day drive from the capital of Thimphu in the far west- over the most massive mountain ranges and through the spectacular scenery to Permagatshel (Place of the Lotus) in the south east. This was not the end of the journey. The twelve enumerators and SNV staff then shouldered their rucksacks and set off on a four hour trek up another few mountains, while Juliet was provided with a long suffering mule to ferry her to the hidden mountainside where the survey was to take place. Ten days later the survey of 146 households had been done and the preliminary results were available.

SANITATION DESIGNS FOR BHUTAN

Anthony Waterkeyn had meanwhile been criss-crossing the country visiting schools and monasteries and households in the poorest settlements to assess the current problems with sanitation. Although Bhutan has made massive strides in the provision of water and sanitation to over 80% of its tiny population of roughly 650,000 scattered through this isolated Kingdom, the decrease in disease has been disappointing. Although latrines do exist in high numbers, there are many that are not used, and those that are used are poorly maintained, and seldom very inviting.

The current thinking in the health sector of Bhutan is that a strong health promotion campaign is needs and Community Led Total Sanitation has been proposed as a method, based on its success in neighbouring Moslem communities of Bangladesh.  However this approach can be misused and become a top down drive by local leaders which may not be appropriate in these gentle Buddhist communities, where rats cannot be killed as they too are sentient beings. Africa AHEAD is proposing the use of the CHC Methodology as there is little doubt that it would be culturally appropriate given the national value for Gross National Happiness.

Another outcome of this consultancy has been the design of a Beautiful Bhutanese Bathroom (BBB): this combines the effectiveness of the VIP latrine in reducing odour and flies, with a shower room, so that washing is encouraged given the added privacy. The squat hole is designed so that it can accommodate a pour flush system, and the squat hole can be exchanged for a seat for the infirm or disabled.  The external design of this versatile latrine matches the houses of Bhutan, one of the most beautiful styles of building to be found in an underdeveloped nation. The latrine is constructed of local wood which is used for the traditional houses. The forests of Bhutan are some of the most extensive in the region and are well regulated by the government   in this eco-conscious  nation. The idea is that toilets should not be an object of disgust but rather a status symbol: every bit as beautiful as the home. At the King’s request all the houses in Bhutan are in the national style of architecture which demands much painting with intricate religious symbols and even an un-Bhuddist eye can marvel at the most humble of dwellings. So the BBB design is not only practical but also in keeping with National values contributing to the unique concept of Gross National Happiness. It is hoped that the BBB may contribute towards the household’s everyday happiness by providing an appealing sanitary retreat, perhaps even a place of quiet meditation where one can escape from daily chores to enjoy a quiet moment to attend to one’s ablutions!

January 19th, 2009 | Tags: Bhutan, Health Department, Health Promotion, Latrines, Line Survey, Water And Sanitation | Category: Community Health Clubs | Leave a comment

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. p.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.

For full article in pdf, click here: Creating Demand for Sanitation and Hygiene Through Community Health Clubs

February 17th, 2008 | Tags: Cairncross, Community Health, Hand Washing, Health Clubs, Health Promotion, Hygiene Behaviour & Practices, Latrines, Makoni District, Millennium Development Goals | Category: Hygiene, Sanitation, ZIMBABWE | Comments (3)

HIDO is an indigenous NGO based in Gulu District in Northern Uganda . It was formed in 2004 by Ugandan medical practitioners and is comprised of an energetic group of recently qualified clinicians and health assistants. It is dedicated to serve internally displaced people caused by the Lords Resistance Army (LRA), which for the past 18 years has terrorised the local population and forced them to flee their rural homes and cluster in vast IDP Camps in the towns. HIDO have for the past two years been providing voluntary services in the improvised night shelters for the thousands of children who trek into town every night to sleep in safety. These children undertake this trek every day to avoid the LRA who have abducted over 20,000 children to work as slave labour in their bush camps and to brutalise them as child soldiers and concubines for their leaders.

HIDO was selected an the main implementing partner of CARE International in a substantial emergency programme working in 15 IDP Camps, to improve public health and sanitation through the introduction of Community Health Clubs. 25 Staff have been trained in the CHC Approach using the AHEAD Model and in 2004 formed 120 health clubs. Their target at that time was to reach 120,000 people with a health promotion campaign and construct 10,000 latrines (Funded by Bill Gates Foundation).  This programme is the first to use this methodology in an emergency context and as such provides a vital case study for future replication. The approach is now being extended into the neighbouring districts of Pader, Kitgum and Lira.

HIDO CHC Trainers Displaying their Certificates

January 6th, 2008 | Tags: CARE, Health Clubs, Health Promotion, HIDO, IDP Camps, Latrines, Training Materials | Category: Associates, HIDO, UGANDA | Leave a comment