Community Health Clubs: 2
Quantifying Behaviour Change:
Health promotion programmes in which concrete achievements in behaviour change can be accurately quantified are more likely to attract financial assistance because they can be shown to be cost-effective.
The A.H.E.A.D Model provides cost-effectiveness health promotion training at less than US$1 per beneficiary per annum (Waterkeyn & Cairncross, 2005).
Cost-effectiveness of Health Promotion through Community Health Clubs :
The Community Health Club Approach is effective because it enables a community to come to a consensus on the management of public health issues. This process of community preparation may initially take longer than the conventional top down implementation, but in the long term, it will achieve far more sustainable results . For example: it is generally accepted that to persuade communities of the importance of sanitation is notoriously difficult as it is seldom their priority. Therefore if a demand for sanitation can be induced this would provide a powerful indicator of a successful strategy for community mobilisaton. This was amply demonstrated in one of the most challenging environments, the IDP Camps in Northern Uganda where agencies had for 18 years failed to convince. More than 11,000 latrines were built within 8 months in IDP Camps in Uganda with demand far outstripping the capacity of the programme.
CASE STUDY: ZIMBABWE
There is also substantial proof based on measuring the many smaller indicators of home hygiene that were changed within health clubs and these have been measured in most of the CHC Projects. Initial research focused on three areas in Zimbabwe where a survey was undertaken of 1,250 households, contrasting Community Health Club family with non health club families.
In one year in Zimbabwe, 1,244 health sessions were carried out by 14 trainers, costing an average of US$0.21 per beneficiary and involving 11,450 club members (68,700 beneficiaries) in Makoni District.
In Tsholotsho District, in a smaller project 2,105 members participated in 182 health promotion sessions carried out by 3 trainers, which cost US$ 0.55 for each of the 12,630 beneficiaries.
MEASURING BEHAVIOUR CHANGE
It is important to measure the cost-effectiveness of a project so that funding will be easier to attract.In this Sector, we also want to know whether our activities are having any beneficial effects on the community. The objective of health Promotion is to lower the rates of illness within a family due to diseases that can be prevented by good home hygiene. In particular we are able to reduce diseases such as diarrhoea, cholera, dysentery, skin diseases, intestinal parasites, bilharzia and Malaria among others.It is often difficult to assess accurately it these diseases have been reduced, either because the % of people suffering from diarrhoea at any one time in a given population is often low, or because there are other confounding factors.
Using Proxy indicators
There is enough evidence to show that if all the hygiene risk practices associated with diarrhoea are routinely overcome, then diarrhoea will be minimised. Therefore instead of ameasuring the reduction of diarrhoea by simply asking people when they last had diarrhoea, it is far more reliable to check the proxy indicators of diarrhoea, because these are empirically observable, and verifiable (can be rechecked by others). A household inventory or a house-to-house survey using proxy indicators will show whether good hygiene is being practiced in the house. A standard check list is prepared and a random sample of homes selected (See below). Enumerators observe what is in place at the time of inspection. Empirical or observable data is used as reported information is not usually as reliable.
There are two ways to measure the effectiveness (outputs):
1. Before and after in the same community:
By doing a household inventory before and after the project; the difference in practices can be observed and therefore measured within the same households.
2. Comparing two communities
If a base line survey has not been done prior to intervention a survey can be done on the Community Health Club area and then compared to a similar area where there have been no health clubs.
There are seldom enough resources to monitor every single member of the health clubs so to achieve results that are accurate it is important to take an accurate sample of the whole population. This is done by random sampling which is an unbiased way of ensuring that every single household would have the same chance of being selected. For example a sampling frame could be made from an alphabetical list of all health clubs operating in the area, and if every fifth club in the list is chosen, all clubs have a fair chance of being chosen, and there will be minimal selection bias. If the number of household surveys is at least 30% of the whole population the results should reflect the rest of the population. By using a statistical analysis that indicates how high the probability (p) of being true to the real picture, the data will be more convincing. Standard deviation (SD) and p values and can be done on computer packages such as SPSS or Stata and will greatly enhance the credibility of the results.
How to measure Cost-effectiveness
As explained above, this ‘Consensus Approach’ methodology is particularly strong in its capacity to calculate cost -effectiveness.
Community Health Clubs can quantify the number of:
* beneficiaries :number of members x 6 (average family size)
* health sessions that have been held
* attendance at each of the sessions per club
This can be balanced with the cost of the trainer in terms of transport and allowances:
Cost per beneficiary = cost of trainer + training + transport
Number of beneficiaries
Cost Effective Health Promotion through Community Health Clubs
Waterkeyn, J. (2005). Cost-Effective Health Promotion through Community Health Clubs. London School of Hygiene and Tropical Medicine. Unpublished PhD Thesis.
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.
For full article in pdf, click here: Cost Effective Health Promotion Through Community Health Clubs-Dissertation
Cost-Effective Health Promotion: Community Health Clubs
Waterkeyn J. (2003). Cost Effective Health Promotion: Community Health Clubs. Abuja. 29th WEDC.
Abstract: Health Promotion is often considered a nebulous activity and funding agencies are often reticent to support it because any achievements are difficult to quantify accurately. It is therefore important that hygiene behaviour change can be measured and a cost per beneficiary calculated. In 1997, the NGO Zimbabwe A.H.E.A.D pioneered a new approach in three districts of Zimbabwe to demonstrate how health promotion could be quantified. The approach was to use Community Health Clubs as a vehicle for dissemination, and with careful monitoring of outputs (in terms of number of participants, health messages understood, and observable hygiene practices), to calculate the cost effectiveness of this methodology. This paper focuses on Makoni District where 14 Environmental Health Technicians (EHTs) conducted 746 weekly sessions in 141 health clubs with an estimated 10,620 active members. At a total project cost of US$28,665 this can be averaged out at a cost per club member of only US$2.70, for seven months of health promotion (or 45c per family beneficiary). As the programme was conducted by the Ministry of Health, the main project costs were provision and running costs of motorbikes, as well as nominal allowances for field staff. Depending on the mileage, numbers of members and health sessions, each EHT’s cost-effectiveness could be estimated. The most successful trainer had 1,804 members (21 clubs) with a low mileage, and as such her cost to the programme was only US$342 in 7 months. Whilst the running costs are low, it is equally important to ascertain whether the training has had an impact. After one year, research was undertaken to establish whether this approach would show a significant difference in health knowledge and hygiene practices between members and non members. A survey of 375 randomly selected members from 25 clubs was contrasted with a control group of 100 non-club members. A clear picture emerged that hygiene practices unique to the project showed a substantially higher uptake in the health clubs, than hygiene practices that had been recommended by MoH for some time beforehand. For example, the pour-to waste hand washing method was 40% higher within the health clubs; there was a 33% higher use of individual cups and plates and a 20% increase in nutrition gardens and safe sanitation. This meant that whilst in non-health club areas cat sanitation was unknown and 41% respondents practised open defecation, in the project areas 14% club members used cat sanitation whilst open defecation was only 12%. This strategy has also proved itself to be sustainable without NGO support. Since March 2001, when the two year project ended, the Ministry of Health has continued to run the Community Health Clubs with its own resources. The A.H.E.A.D methodology has been wholeheartedly adopted and the high level of community organisation due to health clubs has been pinpointed by the Rural District Council as one of the main reasons that Makoni has become a lead district in sustainable community development and the methodology is being spread to other areas of Zimbabwe.
For full article in pdf, click here: Cost Effective Health Promotion Through Community Health Clubs
For a copy of the presentation given at the WEDC Conference in pdf, click here: Cost Effective Health Promotion: Presentation at 29th WEDC Conference, Abuja