Community Health Clubs:1.
What makes people change ?
Does a person change just because they know it would be good for them ? No, very seldom! How many apparently intelligent people continue to smoke although know it is bad for them? They may have the knowledge but it takes a lot of effort to change a habit of a lifetime, and (like Alcoholics Anonymous) only peer pressure and group conformity provides the support that is needed to assist people to change their ways.
Knowledge or peer pressure?
Often development programmes have tried to appeal to the ‘reason’ of the ‘beneficiaries’, and provide information to people in the hope they will change. This ‘Health Belief Theory’ is based on the rational/ individualistic outlook that personal conviction will result in behaviour change and action. However this individualistic decision-making usually goes against the grain of the consensus-seeking traditional worldview, where the individual usually accepts their subordination to the group, and consequently do not like to make a decision that may be different from the norm. To be outside the group is not only uncomfortable, but a definite risk in a conservative society. External influences are resisted by an individual until approved by the group.
The wide range of strategies that have been tried in the last few decades can be grouped according to the overriding incentive used to trigger behaviour change:
People only change when they are forced to do so by authority.
The traditional regulation by governmental control of areas through health inspectors is further reinforced by a system of rewarding compliant households from the proceeds of fines raised from those villagers who do not measure up to set government health standards. This Carrot and Stick approach can be put into effect immediately through government regulation without additional funding or NGO support, and will be most successful if health inspectors are well motivated by recognition and reward. (e.g. Busia District, Uganda)
People will improve their hygiene if they know the reasons why they should do so.
This model is based on the common sense theory, that if someone is well informed they will act on the basis of their information and belief. Thus health education was seen as a prerequisite to hygiene behaviour change (Janz & Becker, 1984). Modernisation takes place ‘naturally’ by the diffusion of this information or innovation from the fast adaptors and innovations and trickles down to those at the lower end of the scale by emulation (Rogers, 1983).
People will only change is they can participate in all stages of their own development
When people failed to change although they possessed the knowledge, a number of progressive development schools identified the problem as being due to lack of involvement by the beneficiaries who were perceived as passive recipients of assistance. As a result much effort was made to enable them to have more participation in their own development, enabling them to make their own choices, and manage their projects. PHAST (Participatory Hygiene and Sanitation Transformation) was the main methodology in the Water and Sanitation Sector, and during the 1990′s a number of countries developed training packages, using visual aids to identify problems.
People are more interested in being smart rather than to improving their health.
The appeal of status is considered as being more effective in creating a demand for a product than knowledge of the germ theory. Social Marketing often engages the private sector (usually soap manufacturers) in a ‘public private partnership’ (PPP) to link with public sector in a media campaign to change behaviour using the subliminal messaging of commercial advertising. Curtis (1993): Burkino Faso. www.worldbank.org
People will change their behaviour when they are embarrassed publically.
Focusing on the human trait of self-respect, planners conduct a village ‘walk of shame’ with village leaders. When the village becomes a faecal free environment, with every household using a latrine the village is declared a faecal free environment. This Community Led Total Sanitation (CLTS) encourages village pride, whilst village leaders continue to enforce compliance. Kar (2004) WaterAid. India. www.wateraid.org
People change more easily when everyone around them is doing the same thing.
Community Health Clubs are formed and a Culture of Health developed through knowledge and understanding in a series of participatory health sessions. Group consensus endorses essential values and group conformity results in high levels of behaviour change with communities monitoring and managing all preventable diseases. This website is the primary source of information for this approach. Waterkeyn & Cairncross, (2006) Zimbabwe. www.africaahead.com
These strategies are not mutually exclusive and all are aspects of the reason why people change, and each may be appropriate in different contexts. For example, Social Marketing and Regulation are more appropriate in urban areas, whilst CLTS and Community Health Clubs are more appropriate in rural areas. They can be used in conjunction with each other as each provides different ways of reinforcing the same key messages at different levels.