Monitoring Hygiene Behaviour Change in Community Health Clubs in Rusizi District

There are 5 main objectives for this intervention in 3 years:

1. To build capacity in MoH for cost-effective training of communities for hygiene behaviour change: Capacity of MoH has been built: 14 EHOs and 7 EHPs were trained to supervise the 100 Community Health Facilitators (known as ASOC) in each village. The M+E Officer at MoH head office has been of great help to the under staffed department.

2. To enable MoH to effectively monitor behaviour change through evidence-based data collection:  Midline and end-line survey were done using a mobile app ‘Mobenzi’.  Both have been uploaded onto the CHC website (www.chcahead.com). Village level monitoring is outstanding with CHC committees taking full responsibility for hygiene practices in registration books and reporting weekly through the CHC Facilitator to EHOs from HC to MoH/EHD.

3. To ensure functional and responsible communities exist in 150 villages in Rusizi district:  50 CHCs are now fully operational, with active executive committees. To-date average coverage of CHCs household in each village is at 58.4%. The average size of a CHC is 79 members. Of the 9 targeted practices, the uptake is 52.4%.

4. To provide a demonstration on how hygiene behaviour change can be sustained: The baseline shows that there was an exceptional high level of sanitation with 99.9% in classic villages having virtually no open defecation even before start-up of training: 9.5% had no latrine or shared a latrine. 69.3% already had clean latrines with no open defecation.

5. To demonstrate a cost-effective Change Model capable of improving family health at scale: This will be measured by the IPA Evaluation Team

• Number of Classic CHCs: 50
• Number of Members: 4,056
• Percentage CHC coverage: 58.4%
• Number of EHTs: 14
• Number of CHC facilitators: 100
• Number of beneficiaries: 24,336 (50 /150 villages)
• Cost of Project: US$925,020 (100/150)
• Cost per beneficiary: US$19 (100 villages)

Targets

With 87% of the disease burden in Rwanda theoretically preventable through improved hygiene behavior, the Community-Based Environmental Health Promotion Programme (CBEHPP) aims to break the fecal-oral disease transmission routes by stimulating strong demand for improved latrines, promoting hand-washing with soap  and ensuring access to safe drinking water.

Community Health Clubs  will be the vehicle for increasing knowledge and altering attitudes and practices so that a new ‘Culture of Health’ becomes the norm throughout Rusizi. As in the rest of Rwanda, the Ministry of Health is aiming to achieve 80% adherence to ‘10 Golden Indicators of safe hygiene’.  In so doing it is expected that   preventable diseases including diarrhea, dysentery, cholera, acute respiratory infections, malaria, bilharzia, skin and eye diseases and intestinal worms will reduce infant and child mortality and morbidity. This integrated programme will also focus on infant care and nutrition to reduce the exceptionally high levels of stunting throughout the country.

Project Progess

• The start up of the CHCs in Year 1 was meant to take place from June 2013. However the randomization of villages was not completed by the evaluation partner (IPA) until August 2013
• This meant that MoH and Africa AHEAD could not begin any interaction with the villages until September 2013. This has delayed the implementation by 5 months. Thus the activites scheduled in  ‘Year-One’ started for MoH and Africa AHEAD in October 2013 instead.
• Training of trainers was done in November 2013, and the training of CHC facilitators was done in January 2014.
• The CHC facilitators then returned to register members and village training sessions started with the community in February 2014.
• By May 2014 all 50 Classic CHCs were functional and there was an average of 77 members per CHC.
• Training sessions continued in the CHCs and by May 2014 most CHCs had completed 10 of the 20 sessions on target.
• Average attendance was higher than targeted 68,9% as against the target of 50%
• Many households were making changes in their hygiene facilities
• The  mid term survey (after 10 sessions) of 650 households shows significant improvement in all targeted activities
• The end line survey was completed by May 2015,  which showed improvements in all indicators, with 7 over 80% adherence.

Above: Training of EHOs in Rusizi District, November 2014

2015 Activity Plan

The project is on hold until the post intervention data has been collected by IPA, the evaluation partners. This will be completed by october 2015. After that, when the rains have subsided in February Africa AHEAD will work with MoH to ensure that the 50 Lite villages which have received only 8 hygiene sessions and the 50 Control villages which have received no training, all receive the full classic CHC training and can be at the same level as the intervention classic CHC villages.

Hygiene Achievements 

The hygiene targets for this project were all set at 30% for end of Year 1. Five of the 9 indicators had exceeds targeted levels as shown below. By the end of May  2014, the following levels were attained in 50 Classic CHCs:

• 70.6% have clean hygienic latrines
• 56.8% practice hand washing with soap after defecation
• 52.8% are treating unsafe water
• 85.2% have no open defecation
• 85.2% have no children’s faeces in the yard
• 75.1% use bath shelters for washing
• 41.3% have and use rubbish pits for solid waste disposal
• 32.2% yards are swept clean
• 94.5% have safe storage of utensils using pot racks or similar

Hygiene improvements after 20 hygiene promotion sessions (one year of being in a CHC) June 2015.

• 59.1% with treated drinking Water
• 89.3 with improved latrine
• 87.9% with clean latrine
• 84.6% with appropriate handwashing facility
• 76% using handwashing facility
• 77.2% have soap at hand washing facility
• 88.9% produce compost from organic waste
• 69.7% have safe food preparation
• 97.3% store utensils safely
• 66.3% use a fuel efficient stove
• 69.1% have ventilated kitchens
• 88.6% now have a proper kitchen floor
• 64.7% have safe access path to the house
• 82.2% now grow vegetables
• 69.1% now have safe drainage

Challenges & Lessons Learnt

• Being an experimental project means that implementation is less flexible as it is governed by research demands
• Time taken for randomisation meant that we are training in the rainy season which was not as designed for optimal response.
• Given this was one of the most challenging district, much more time was needed for inclusion and buy in  of all levels of District CBEHPP including Sector and Cell levels
• Budget was not enough for advocacy at all levels in the District which was need to open the gates for village implementation
• Very little feed back or mutual planning by the evaluation team who operated independently
• Limited budget for personnel in this project and more was needed as demanded by District and also in order to be a functional partner at head office. i.e. full time local staff are needed not just external consultants.