A Case Study Evaluation of Community Health Clubs in Port au Prince, Haiti
2015. Waterlines, 34(4).
Jessica Brooks, MESc1; Alexandra Adams, MPH1; Nora Moraga-Lewy1; Samy Bendjemil2; Ruth Berggren, MD2; Jason Rosenfeld, MPH2
(1) Yale University
(2) University of Texas Health Science Center at San Antonio
After an absence of over a century, cholera is now expected to remain endemic on Hispaniola until the underlying structural, behavioral and social conditions on both sides of the island are addressed. While government and civil society have made progress re-building capacity and increasing access to basic water (62% nationally, up from 61% in 1990) and sanitation infrastructure (24% nationally, up from 19% in 1990)(1), many communities remain fragmented, dysfunctional, and increasingly dependent upon top-down health education strategies. Without an integrated, community-based approach to health education that emphasizes behavior change and creates common-unity, Haitian communities will be unable to build resiliency and sustainably address health threats like cholera.
Since 2012, the Center for Medical Humanities & Ethics at the University of Texas Health Science Center San Antonio, in collaboration with the Eco-Eau et Jeunesse (Eco-Water and Youth) Haiti organization, have been training community-based facilitators to provide participatory education and stimulate common-unity through Community Health Clubs in Port au Prince. To date, 23 Clubs with over 1,200 members across 12 communities have been formed, with over 550 members completing the entire 23 week curriculum. Between June and July 2014, graduate students from Yale University and the UT Health Science Center completed a retrospective case-study evaluation using mixed methods in a purposive sample of 3 communities to demonstrate the outcomes of the first two years of this innovative health education and community development program in Haiti.
The Community Health Club (CHC) approach(2) is a Participatory Health and Hygiene Education methodology developed by Zimbabwe AHEAD in 1995 that has been recognized as one of most cost-effective approaches to WASH education and service provision(3). To date it has been adapted and implemented in 9 African countries, 1 Asian country and most recently in the Dominican Republic and Haiti. In Haiti, 23 Clubs have been formed in 12 communities in Port au Prince since 2012. An additional 25 new facilitators were trained in July 2014 and are currently in the process of forming new clubs
This study collected primary data using both semi-structured interviews with CHC facilitators and from household surveys with both CHC graduates and non-members in three case communities (red text in Table 1). The interviewed facilitators (n=12, N=14) led Health Clubs that have graduated members and represent a wide range of communities across Port-au-Prince (e.g., Cite Soleil, Canaan, Sarthe, and Carrefour Feuilles). Three communities were selected for a case-study approach, based on the following criteria:
- safe to enter, deemed by our local partners;
- availability of the facilitator, to find the graduates’ place of residence and establish trust; and
- the greatest number of graduates
In-person surveys were conducted to assess differences in health knowledge and practices and socioeconomic characteristics between health club graduates and non-members. The surveys were conducted orally in Haitian Creole with both a U.S. team member and a local partner who served as a translator when necessary. All households with graduates that were both available and eligible were surveyed. Graduates were deemed ineligible for the survey if under 18 years of age or were currently living outside of the selected case communities. In households with more than one graduate over 18 years of age, only one graduate was selected. Non-member households were selected by systematic sampling every nth household, excluding graduates’ households. Household members were not selected randomly due to time constraints. Our sample characteristics are provided in Table 2. (See Poster)
The survey instrument was adapted from previous surveys conducted with CHC members(4) and developed in consultation with local community health workers. The survey was translated to Haitian Creole and back translated to ensure accuracy. For the knowledge questions, respondents were asked to provide up to 5 times to wash hands and 5 ways to prevent diarrhoea, skin diseases, worms, and malaria. The number of correct responses given for each question were summed to create a total WASH knowledge score (0-25). Scores were then grouped into 4 bins using the IQR; Low (0-7), Medium Low (8-10.5), Medium High (11-14), and High (14-25).
CHC Members are significantly more likely to have a high binned WASH knowledge score (86.4%) than Non-CHC Members (13.6%), chi square, χ2(3, n=198) = 110.1, p<0.0001.
Weak, negative correlation between Age and WASH Knowledge, r=(-0.249), n=198, p
<0.0001; independent of CHC membership.>
Of HH without a latrine or WC (n=45), Graduates are more likely to share a neighbors/friends facility (84.6%) than openly defecate, as compared to Non-Members (43.8%), Fisher’s Exact Test p
Community Perception of Clubs
Community participation in Club activities was limited by mobilization strategies; distrust of facilitator’s volunteer status and intentions; limits on free time; and a perceived need for incentives.
Only 26% of Non-Member HHs were aware of the Club in their community. Community Distrust “…when you have a club, people don’t realize that you are voluntary by doing this. They always think that they think you are being paid and don’t want to share it with anyone.”
Behavior Change Challenges
Impact of Community Distrust
“Sometimes we try to make a clean-up of the community […] But sometimes the young ones in the club don’t really do it. Because people in the community think they receive money for that. And sometimes people in the community give us a lot of problems […] they say we have an organization, we have money, and those words sometimes discourage the younger people.” – Facilitator (0606_001)
Perceived & Actual Resource Limitations
“If we talk about […] the practicality of defecating, and if there are some people that don’t have latrines or toilets in the first place, as a facilitator I don’t want to just talk about how things should be done. […] But really in fact, it hurts me a lot. Because I’m in the community talking about the subjects, and we all know about the consequences, but we don’t have the financial means to do anything about them. […] But effectively, until now we haven’t found any partners or available government branches or representatives to help us with those activities.“
This data begins to demonstrate some of the differences between Community Health Club graduates and non-members in Port au Prince, Haiti. Despite limitations in mobilization and recruitment that resulted in ‘young’ Clubs, Club graduates, regardless of age, demonstrated more preventative WASH knowledge than non-members. However, behavioral changes require more than knowledge. While the survey found few significantly different behaviors between graduates and non-members, the qualitative data suggests Health Clubs foster positive social relations that can positively improve health-related behaviors. Toilet sharing demonstrates how Club Graduates utilized the increase in trust amongst their peer group as behavior change strategy. We hypothesize that wider community participation in CHCs is hindered by mobilization strategies, distrust and dependencies created by a history of misguided handouts, and the perception Clubs are for young people. These results are important for refining the dimensions to be measured under a prospective outcomes study with a larger sample size.
- World Health Organization and UNICEF (2013) Progress on sanitation and drinking water: 2013 update. Geneva: WHO, Available at: http://www.wssinfo.org/fileadmin/user_upload/resources/JMPreport2013.pdf.
- Waterkeyn, J. and Cairncross, S. (2005). Creating demand for sanitation and hygiene through Community Health Clubs: A cost-effective intervention in two districts of Zimbabwe. Social Science & Medicine. Vol. 61, pp.1958-1970.
- United Nations Development Program. (2008). Poverty, Health and Environment: Placing Environmental Health on Countries’ Development Agendas. Joint Agency Paper.
- Rosenfeld, J., Berggren, R., & Paulino, F. (2013). Measuring behavioral changes associated with Community Health Clubs in the Dominican Republic. 2013 Water and Health Conference: Where Science Meets Policy, Chapel Hill, NC. Peer reviewed oral presentation.
A special thanks to the Eco-Eau et Jeunesse Haiti organization, who hosted the student researchers this past summer and provided the logistics for this evaluation. This research would not have been possible without the support of faculty from Yale University and the UT Health Science Center; thank you for your guidance and support. Finally, thank you to the Health Club facilitators for making community introductions and assisting with data collection activities.