WELL BRIEFING NOTE 38                              Go Back

The most effective way to reduce the incidence of diarrhoea is to create a completely hygienic environment, which all members of the community support. However, this involves considerable effort on the part of housewives and mothers, which can result in a lack of commitment to carrying out the necessary tasks. Promoting a ‘culture of health’ means that healthy living becomes highly valued, bringing about behaviour change, through peer pressure and the desire to conform.

Community Health Clubs

Community Health Clubs (CHCs) help to promote this culture of health because people meet regularly to learn about and discuss ways to improve hygiene. The meetings are properly organized sessions with a registered membership, which should represent at least 80% of households in the community. Private behaviour then becomes a public concern, with the general consensus from the critical mass ensuring that all individuals are discouraged from poor hygiene behaviour in favour of agreed and accepted standards and norms.

Weekly meetings of CHCs can address up to 30 different topics over a six month period. Each session requires members to practice their new learning at home. This can involve simple changes like covering stored water or using a ladle. More demanding challenges include building latrines, which requires effort and resources but is the natural culmination of such behaviour change and comes from within the community rather than being externally imposed.

All members are issued with membership cards, listing the topics covered and recommended practices. This is important as it provides a sense of identity and encourages others to join, setting learning targets, acting as a monitoring tool for programme managers and preventing gatecrashers from reaping unearned benefits. At the end of the six month period, attendance certificates are awarded which confer important social status and are a huge incentive for members. They may be the first qualification ever gained by members and can lead to additional responsibilities in the community, as well as offering the chance to progress to the next stage of the programme.

Although CHCs can move on to wider development initiatives other than health education, this is a good first step and builds community understanding and consensus. CHCs become truly representative CBOs, with a tried and trusted leadership, handling considerable resources, and with the necessary monitoring systems in place.

CHCs are open to all, both men and women. However, for women especially, CHCs can make a real difference to their social standing. They report improved relationships with in-laws, due to their knowledge of health and hygiene issues, and with their children, who give them more respect as educated mothers. Marital  relationships can also improve, with women gaining their husbands’ support for attending meetings. Women can sometimes also earn extra income through their involvement with CHCs.

Loike Munukwa, 70

I wanted to do whatever everyone else was doing, so that is why I joined the club.  Yes, I finished 20 lessons, although at times I did not attend because of illness or deaths, but I completed my card, and I graduated.  Those lessons were very good.  My head, my brain was woken up, you know that means stimulated.  Brain stimulation.

Mrs Mukaesa, 50

My in-laws are now considering me as a very good asset at home because I have got the necessary knowledge and I am not the type of wife who can just go around in the neighbours gossiping.  I am now quite responsible at home and quite knowledgeable.  In fact I cared for the relatives of my husband who were sick, two of them, and I was given a cow to thank me for the good work I did.

Naboth Toriro, 50

There is quite a lot of changes there, because there is a lot of awareness in health ... well let's go to water and sanitation, where do we put it to combat diarrhoea and things like that? Then let's go onto things like AIDS awareness. Let's go to things like drugs where you have some knowledge in things like medicine.

Andrew Muringanidza, Project Officer ZimAHEAD interviews Mrs Simisai, 30

You know my children are also participating in this thing.  They are collecting flowers and plant them at home, and you see any fruit, they plant it.  They participate in maintaining the yard and borehole. They each have a plate and cup, they don't use the same one.

This is an idealized model of holistic development rather than a blue print and demonstrates the broad spectrum of issues which can be addressed.

The table below provides an example of resources required to scale up to national level for a population of 10 million, to meet the MDG target for sanitation.

 Establishing a national CHC

Four main resources are needed:

Trainers: Where trained government health workers exist, these are the preferred option for sustainability. Where this is not available, capacity can be built by using field workers from an implementing international NGO.  Indigenous NGOs can also provide effective trainers, who integrate well with local communities.  Alternatively, the NGO may need to train community members themselves, as a cost-effective and sustainable strategy, despite the steep learning curve involved.

Transport:  This covers bicycles, motor bikes, vehicles and bus allowances.  Access to the communities is vital in spite of insufficient transport funding.

Training material: Culture-specific visual aids are important.  Their preparation needs formative research, with pre-testing to ensure that key messages are understood by all.  Successful visual materials focus on single messages, with simple depictions of attitudes, objects and situations that are typical of the area.

Training: CHC intervention uses a training technique based on Participatory Health and Sanitation Transformation (PHAST) principles to empower people with a sense of worth and self-efficacy.  CHC participatory sessions are planned within a defined structure of active application of good hygiene and sanitation principles.  Materials used can be easily assimilated by all and are stimulating and fun.  Each week, 'homework' is undertaken, which is followed up at the next session.

Funding for health promotion projects can be difficult to find because the benefits are not as easy to quantify as counting, for example, the number of latrines built. However, using Community Health Clubs allows accurate measurement of specific targets. These can be the learning areas listed on membership cards, and the observed rates of uptake of explicit recommended practices. Membership can be accurately sampled, and hygiene behaviour change measured against the costs of implementation.

The cost can be calculated because the method:

1. has a definite target population and the number of members can be counted accurately;

2. can count the number of beneficiaries: number of members x 6 (average family size);

3. can count how many health sessions have been held;

4. can count the number attending the sessions and the average attendance per club;

5. can count the cost of the trainer in terms of transport and allowances.

Therefore the cost per beneficiary can be calculated:

Cost per beneficiary  = cost of trainer + training + transport

                                                Number of beneficiaries

Evidence suggests that if risk practices associated with diarrhoea are routinely carried out, diarrhoea will be minimized. As it is difficult to measure diarrhoea incidence, it is more reliable to check proxy indicators i.e. whether the hygiene practices linked to diarrhoea have improved. House to house surveys can be  used to ascertain levels of compliance with good hygiene practice. This can be done either by taking a base line survey followed by a post-intervention survey, or  by comparing a CHC area to a similar area where there are no health clubs.