Behavioural change
approaches “The CHC
approach”
COMMUNITY-BASED
COMMUNITY-BASED ENVIRONMENTAL
ENVIRONMENTALHEALTH
HEALTH
PROMOTION
(CBEHPP)
PROMOTION PROGRAMME
PROGRAMME
(CBEHPP)
•
•
•
MoH
Environmental Health
Enhancing human
& natural resources
MINEDUC
MINAGRI
National
development and
CBEHPP
(CHCs)
MINALOC
Increasing access to
rural & urban WSS
MININFRA
poverty alleviation
MINECOFIN
Water & Sanitation Programme of
World Bank
 UNICEF
 WaterAid & KHI
 Applied Health Education and
Development (AHEAD) for private
technical support
 Lux development
 World Vision
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Rulindo
Ngoma
Muhanga
Bugesera
Nyabihu
Rubavu
Burera
Musanze
Rwamagana
Gatsibo
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Defining CBEHPP Roadmap
Mapping CBEHPP with development partners
Developing guidelines for establishing CHC
Developing of CBEHPP tools
Training of CBEHPP National core team
Orientation meeting in ten Districts
ToT training in nine District (220
participants)
2000 sets of CHC dialogue tools, 2000 CHWs
training manuals, 400 EHO training manuals
and 20,000 membership cards printed
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Training of Community Health Workers in
Nyabihu (1419), Burera (272) and Bugesera
(82), total of 1773
Establishment of community hygiene clubs to
79%
Approval of CBEHPP tools by MOH
that top ten leading causes of morbidity and mortality
are caused by infectious diseases
• that over 90% of consultations at the rural health
facilities are preventable
• that they include malaria, diarrhoea, skin diseases,
typhus, cholera, intestinal parasites, acute respiratory
infections (ARIs), HIV/AIDS, STIs, tuberculosis,
meningitis and
• that 66% of school children are infected with worms
• that and 44% of pupils suffer from amoebiasis.
• That these are related to inadequate facilities for
waste management and unhygienic practices.
•
Ibikorwa , imyifatire ku isuku n’isukura
n’ingaruka z’umwanda
1. Ingo zivoma amazi ku masoko
atunganijwe
(CFSVA)
2. Ingo zinywa amazi meza (IDHS)
3. Ingo zidafite imisarane muri rusange
(IDHS)
4. Ingo zifite imisarane ivuguruye
(CFSVA)
5. Ababyeyi bakaraba intoki n’amazi
n’isabune
bavuye ku musarane (CFSVA)
Umwak Ijanish
a
a
(%)
2009
81%
2009
2009
41%
03%
2009
56%
2009
58%
Percentage of children under
five years who had symptoms
of ARI, fever, or diarrhea in
the two weeks preceding the
survey (PDHS 2010
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Diarrhoea in children between 12 – 23 months
were reported to 25% whereas 6 – 11 months were
22%
Anemia in children 6-59months
◦ Moderate 14%
◦ Mild anemia 24%
◦ Any anemia 38%
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Malnutrition
◦ Stunted (height for age) 44%
◦ Wasted (weight for height) 3%
◦ Under weight (weight for age) 11%
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Mortality
◦ Infant mortality 50/1,000 live birth
◦ Under fives 76/1,000 live birth
◦ Maternal mortality 487/100,000 live birth
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Access to improved water source: 74%
Drinking treated water 49%
Households using improved toilets 55%
Households with places for handwashing 10%
Handwashing with soap 21%
The MDG Challenge : 11 million people in RWANDA
?%
unhygienic
latrines
44% = 5 million
x 40kgs faeces per annum
= 200 million tons per annum
Have the
‘Great Unserved’
agreed to change?
What is different?
We have failed to
get behaviour
change from
communities.
Why ?
Social Planning
People only change when they are forced
to
do
so
by
authority.
1970’s
1980’s
Health Belief Model
People will improve their hygiene if they know the reason
1990’s
The Participatory Approach
People will change if they participate
PRA: Participatory Rural Appraisal
PHAST : Participatory Hygiene and Sanitation Transformation
2000’s
Social Marketing
People are more interested in being smart than healthy
APPEAL TO STATUS :
SUBLIMINAL METHOD
• National health days
• Radio and TV programs
• Flyers and pamphlets
• Advertising on posters
• Celebrity advertising
• Community drama
Source: Curtis et al. (2001) Photo: Matthews B. 2005. Malawi Sanitation Programme
2000’s
Community Led Total Sanitation (CLTS)
People will change their behaviour out of self respect
Psycho-Social Perspective: Public Name and Shame
Source: Kar, K & Pasteur, K. (2005) Subsidy or Self-Respect? Community Led Total Sanitation.
An Update on Recent Developments. IDS Working Papers - 257.
2000’sCommunity Hygiene Club Approach
People change through peer pressure / Group Consensus
I fear the jealousy
of others if I change.
Pull her down (PhD)
Syndrome
I am not sure if
the decision is
correct
I don’t like
being
different
from others
I prefer to
wait and see
if changes
bring reward
1995: COMMUNITY HYGIENE CLUB (CHC) Approach
Clubs have 50- 100 members ; They meet weekly in one hour for at least 6 months
Learn and discuss together using participatory activities (PHAST)
Source: Waterkeyn, J and Cairncross, S. (2005)
See|: www.africaahead.com
How is the CHC Approach Different?
Reinforcement: Peer pressure / home visits
Homework: Recommended Practices
Measurable: Specific Targets Each Week
Concept of community participatory
programming
Community
diagnosis
Monitoring
&
Evaluation
Participatory
planning
Implementation
of activities
Community Hygiene Club Methodology
Applied Head Education and Development (AHEAD)
A Process of Development using Community Hygiene
Clubs as a Vehicle for Change
Hygiene
Promotion
Sanitation
Home based
Care / HIV Water
Community
Health Hygiene Club
Education
2003
Sierra Leone
0% - 98% ZOD in one year
Post conflict villages being reconstructed
% CHC Members
43%
Latrines built
Cat sanitation
57%
Demand Led Sanitation in Zimbabwe : 1998/99
8,000 latrines constructed in 1998 in 57 Districts
2,400 latrines constructed in 1999 in 2 Districts
Project
23%
Project
Nation
77%
Nation
Roles and
Responsibilities of
CHC
Executive Committee
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What are the positions required for the
executive committee members?
Brainstorm the roles and responsibilities for
the different positions of the executive
committee members.
How would you facilitate selection of the
executive committee members?
DISCUSSION : the ideal attributes of each officer to ensure that the correct
people are elected.
An Executive Committee is made up of at least six people (6-8) who will
guide the CHC:
Chairperson: It is preferable to have a woman as a chairperson if the
majority of people in the CHC are women. She should be someone
who is highly respected in the community, and has a strong
personality to lead others and make decisions without being afraid.
She also needs to be an inspiration and a good example, leading the
kind of life that is appropriate for the head of a health club.
Vice Chairperson: This can be a man or a women, who can take over if
the Chairperson is sick or absent. They should have the same good
character as the Chairperson
Secretary: It is most important that this person is literate and well schooled,
as well as neat and methodical, with good handwriting and careful
character. She or he has to keep all the records of the health club,
especially the register, household inventory and minutes of meetings.
Vice Secretary: This person should stand in for the secretary if she or he is
absent, and also assist in the above duties so that all the information is
not in the hands of one person.
Treasurer: This person is only needed if money is collected within the club or
if there are donations that need to be recorded. Obviously he/she must
be a very honest person who has never had any complaints against
him/her. She must also be in a position to keep money in a safe place
or be able to travel to town to bank the money. Of course she/he must
have a good education and be very numerate.
Vice Treasurer: She/ he must assist the treasurer and make sure that all the
money is kept in a transparent way. If there are any doubts she or he
must alert the Chairperson.
Facilitator: If the facilitator for the health sessions is CHW, she/he should also
be on the executive committee to help and guide all activities as she/he
is the most qualified in this respect. Once the duties of facilitation are
over, she/he should become the Water and Sanitation and Hygiene
Officer, who will continue to be responsible for monitoring the public
health issues in the areas, and alerting the authorities or CHC if there is
any need for action.
WHO SHOULD NOT BE ON THE COMMITTEE
As CHCs should always make sure that they are not affiliated with any
particular political party or a particular religion. No politician, councilor,
traditional or religious leader should be given a position on the Executive
Committee because this may lead to others refusing to join, or to the CHC
being used for purposes other than the improvement of health.
METHOD: VOTING
 Ask the group to nominate people for each of the jobs that need to be done.
 Give each person a small piece of paper and let each write the name of one of
those who have been nominated. Let them vote in private and count who has
won.
 Announce who has been elected and congratulate the winners.
 Explain that they will be officers for one year after which there must be new
elections at an Annual General Meeting.
 Plan when and where the next meeting will be.
 Arrange to meet the committee on their own to discuss the way forward.
A membership card is the key to the programme,
standardised
content
of training
1
Introduction
Health Slogan
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Registration
Mapping
Scabies
Ringworm
Roundworm
Threadworm
Diarrhoea
Food Practices
Food Story
Safe Water Chain
Saving Water
Refuse Disposal
Sanitation sorting
Sanitation ladder
Sanitation story
Sanitation planning
HIV/AIDS story
HIV/AIDS prevention
Graduation
Health Song
Clean clothes/bedclothes
Scabies treatment
Worm treatment
Clean children/fingernails/hair
Clean pets/well controlled
Food safe/covered food/shelves
Squeeze bottle/soap
No dirty plates/pots
Covered drinking water
Jug/ladle for drinking water
Good refuse disposal/swept yard
No faeces nearby home
Clean latrine & roster
Well maintained latrine
Cover on latrine/bucket
Oral Rehydration Solution
ABC - use of condom
Home pride/flowers/tree
No Material Handouts: The Only Reward is a Certificate
Planning Community
Based Environmental
Health Promotion
Programme
10. PLANNING: SETTING REALISTIC TARGETS
It is important to know when you start the programme exactly what you are trying
to achieve in terms of targets.
1. How many Health Clubs do you expect to be able to achieve in one year?
The number of CHCs that you can do in an area depends entirely on the amount of
time the Village Health Worker can give to the programme. At a minimum she should
be able to run one health club, meeting once a week for two hours. However if she
can meet one health club every day and can manage 5 per week, then the program
becomes much more cost-effective. As the training takes six months, she may be able
to do 10 CHCs in one year. This is the extreme and few manage to coordinate this
many CHCs at once.
2. How many members do you expect per health club?
In most countries CHC members number between 50 and 100 members. The amount
depends on the density of the population, the season when the training takes place,
and the charisma and competence of the facilitator. Even if the clubs are small (less
than 30 members) it is worth persevering as they often expand later once people have
seen what they are about. When a club becomes bigger than 100 it may be worth
splitting it into 2 clubs to enable easier communication at the sessions.
3. What percentage of households in the area should be represented in the health
club?
You should aim for all households to have a representative in the CHC. However, this
is seldom possible practically so aim for at least 50% the first year and 80% in the
second year.
4. How many months will the health promotion training continue?
The training is designed to last for 20 sessions of about two hours each, to be held
every week for six months. However it usually takes about a month to mobilize the
community to join, as well as to conduct a base line survey (household inventory). In
addition sometimes sessions are delayed because of rain, holidays, funerals and other
reasonable priorities, so usually it takes 8 months to complete the 24 sessions.
Sometimes the community asks for repeats to enable them all to catch up on missed
sessions so they can get their certificate. So to be able to be unstressed it is usually
wise to plan one intake of members each year rather than try and squeeze in two
intakes in a year.
5. How many of the sessions do you expect each member to complete?
Of course we would want every member to complete all 20 sessions, but this is setting
a very exacting standard which will not be realistic. Past experience has shown that
50-60% of all members are able to complete all the sessions.
6. What do you expect in terms of the average attendance at each meeting?
Attendance means the number of people at each session compared to the total
membership. Adding the attendance of each session and taking an average of all
sessions, is a simple way to monitor the relative success of each CHW, and will also
enable managers to see which facilitators are the most cost effective, by dividing
their costs by the average attendance. Past experience has shown average
attendance is between 30 - 50% of the membership. In CHCs where attendance is
compulsory, average attendance can be 80-100%.
7. What do you expect in terms of % members following all recommended
practices?
We can measure how much change is taking place in the Community Hygiene Club,
by monitoring the hygiene practices of the members. We see what the situation is at
the beginning and then compare to after the training. The difference between the two
is the percentage (%) of change. To monitor change is to best to monitor all the
members, but if this is not possible due to time constraints then at least 30% of the
households should be surveyed. CHC projects in the past have achieved between
20% to 47% change (Waterkeyn & Cairncross, 2005).
DISCUSSION:
•Think
of some of the issues that may be a problem and how this could be worked into
the planning
•
•SETTING
TARGETS: Discuss the targets that are appropriate for your area.
•
How many functional Hygiene Clubs do you expect to be able to achieve in one year?
How many members do you expect per hygiene club?
What percentage of households in the area should be represented in the hygiene club?
How many months will the health promotion training continue?
How many of the sessions do you expect each member to complete.
What do you expect in terms of the average attendance at each meeting?
•Remember:
•The
training in CHC usually results in a strong demand for sanitation, so management must
have a strategy to offer in terms of assistance for sanitation. The CBEHPP does not offer
financial assistance / subsidy for the construction of latrines. The group has to make their own
plans as to how this can be done at a basic level
•What
will you do if there is a demand for latrines to be built?
•What
will you do if there is a demand for safe water infrastructure to be built?
•Train
a latrine builder in each CHC so there is local skill available for hire by CHC members
themselves
Link the CHC up with the local Women’s Union which could assist in starting a revolving fund
for latrine construction
•
Link the CHC up with the local promoters for the Rwanda Bank of Social Policy water and
sanitation loans
•
•Provide
•
latrine subsidies only to the poorest of the poor
Develop a training plan for the CHWs in your
districts?
Note
• Role of the CHWs in CHC start up
• Content based on their responsibilities
• Training plan of not more than one day
• Develop the necessary budget
• Strategies to mobilization required resources
•
But may include:
• What are the objectives
• What are the key activities
• What is the schedule and when
• Who is responsible for what
• What are the indicators/targets
• How will the results be verified
• What will it cost