The performance of Community Health Clubs in transforming sanitation

conditions and hygiene behavior: A case - control study in Kicukiro and

Rusizi districts in Rwanda. 1Ntakarutimana, A., and

2Ekane, N

¹University of Rwanda-College of Medicine and Health Sciences, School of Health Sciences;

²Royal Institute of Technology (KTH), Stockholm, Sweden

Abstract

Introduction: Lack of appropriate approaches for implementing sanitation policies causes contradictions

between prescribed formal sanitation and hygiene standards and guidelines and prevailing norms,

behaviors and practices in communities/ households. This gap between policy and practice is a common

problem particularly in the developing context. A number of community based approaches are being

implemented in different settings to improve sanitation and change hygiene behaviours. For effectiveness,

there is a need for promoting approaches that can facilitate sustainable behaviour change and practice at

household level. This paper presents the results of a case - control study conducted in Rwanda with focus

on the performance of the Community Health Club (CHC) approach that is implemented under the

nation-wide Community Based Environmental Health Promotion Programme (CBEHPP). Community

Health Clubs (CHCs) were introduced in Rwanda in 2010 and are being rolled out in rural and peri urban

settings. Methodology: As cases for this investigation, we selected two villages from a rural setting

(Rusizi district) and two villages from peri urban setting (Kicukiro district). In both settings, we had one

intervention village (case) with exposure to the CHC approach, and one control village with no exposure

to the CHC approach. Household questionnaire based surveys were conducted in 798 households (95%)

and spot observations also performed. Focus group discussions and interviews were conducted with

village members, local leaders, sanitation professionals and opinion leaders in both settings 3 years after

CHC implementation in Kicukiro and Rusizi. Results and discussion: The probability of improved

sanitation and hygiene practices of households from rural and peri urban settings was estimated through

risk difference (RD) which is high (RD>>0) with (p=0.000) in all cases. The improvement in sanitation

and hygiene conditions from the exposed villages/communities is associated with CHC approach

implementation. In addition to accountability rules and organizational structure at community level, the

CHC approach implementation has created a social support network which empowered households from

CHC villages/communities to improve and sustain sanitation and hygiene conditions 3 years after the

intervention and beyond. Conclusion: This research shows that CHC approach implementation is

associated with households’ sanitation and hygiene practices improvement 3 years after the intervention

in Kicukiro and Rusizi. The improvement is supported by a natural social support network which is

restored spontaneously and strengthened by CHC approach implementation. Further research is needed to

assess its effectiveness compared with other similar approaches and its scalability in different eco socio

economic conditions.

The performance of CHCs in transforming sanitation conditions and hygiene behavior

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Introduction

The need for effective sanitation and hygiene promotion approach

While great efforts and investments to improve water sanitation and Hygiene (WASH) practices

especially in sub-Saharan Africa (SSA) are being made at different levels, there is a need for

promoting approaches that can facilitate sustainable behaviour change and practice at household

level (WaterAid, 2011). Our attention is put on rural and peri urban settings which are not often

well served compared to urban settings especially in Rwanda (Rwanda Ministry of

Infrastructure, 2010). WHO (2004) advocates for households to (1) be vocal and active

encouraging local authorities and neighbours to improve and maintain sanitation facilities, (2)

learn about and demand their rights and responsibilities on sanitation, (3) participate in training

programmes and teach other members of the community the necessaryessentials on operating

and maintaining sanitation facilities and practicing good hygiene, (4) adopt good sanitation and

hygiene practices and with local political representatives, support locally developed solutions,

and (5) mobilize financial resources for subsidized sanitation services through community

schemes and/or micro-credit schemes; pay back loans to loan providers; and contribute

maintenance fees to user groups. Bartram and Cairncross (2010), explains that active

involvement of health professionals is crucial and that the type of approach used matters. The

purpose of this study is to investigate on the performance of the CHC approach in transforming

sanitation and hygiene behaviour of households from rural and peri-urban settings in Rwanda. It

is envisaged that the study results will contribute to appreciate what works to make sanitation

happens for possible replication for improved and sustainable sanitation and hygiene practices at

community and household level. Indeed, Rwanda has adopted the CHC as a National approach

for sanitation and hygiene promotion recognized by the sector working group. This has been

implemented since 2010 (Rwanda Ministry of Health, 2010). To date, we have professional

reports on the CHC activities from some districts but no research has been done to quantify its

potential contribution on households sanitation and hygiene behaviour change in Rwanda. The

present paper comprises an introduction with a short description of the objective of the study, the

CHC approach and its implementation, study methodology, presentation of results and

discussion and a conclusion.

Principles of Community Health Club implementation

The Community Health Club (CHC) approach is one of the community based approaches

widely implemented so far mainly in Zimbabwe (Waterkeyn and Cairncross, 2005), Uganda,

Rwanda and Democratic Republic of Congo (DRC). This approach exploits common unity and

building consensus among community members to solve community problems. The works of

Cairncross and Waterkeyn (2005) highlight the potential results of CHC implementation in

Zimbabwe from where the approach has been experimented from the first time.

Waterkeyn and Cairncross (2005) suggest a club to be composed by between 50 and 100

members representative of households in the village and a household is represented by at least

The performance of CHCs in transforming sanitation conditions and hygiene behavior

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one person preferably the head and maximum two persons. The clubs are formed in each village

by households’ representatives who register and are gradually trained. tThe training consists of

one session of one to two hours per week. Dialogue session /group discussions and consensus,

demonstration, slogans, songs, dancing and drama are used to ensure the trainees have acquired

knowledge, motivation and change to complete the recommended practices assigned after each

dialogue session.

The CHC members elect a committee for the management, monitoring through

households’ visits and checking of the accomplishment of recommended practices. Peer pressure

within the club, knowledge, and appraisal support develop and facilitate a shared understanding,

common ethos and objective, and genuine commitment to change.

After at least 6 months of dialogue sessions, a competition is organized between CHCs

and best performing CHCs are awarded a prize as an incentive. Also, a graduation is organized

and CHC members (households) who completed their dialogue sessions and recommended

practices get a certificate.

The beneficiaries of the knowledge and skills will be the whole household members

since the household representative in the CHC teaches the entire household members for

practice. The communities who pass to action and sustain hygiene and sanitation in their

livelihood lead into a socio capital for investment beyond hygiene and sanitation due to dialogue

sessions (Waterkeyn, 2006).

The CHC Approach addresses a wide range of preventable diseases within a holistic

framework of development that understands health promotion as an entry point into a long term

process of transformation of social norms and values that ultimately leads to poverty reduction

outcomes.

Community Health Club implementation in Rwanda and targeted districts

The CHC approach is implemented in a number of districts in Rwanda including

Kicukiro and Rusizi districts and has been a government strategy to improve sanitation and

hygiene through the Rwanda Ministry of Health since 2010 and remains the main approach used

country wide. Our documentation on CHC implementation in Rwanda focused on how CHCs

emerge, how they are coordinated and regulated as well as how they are appreciated by

community members and local leaders.

How Community Health Clubs emerge?

CHC approach was adopted in 2010 and is supported by the government through Ministry of

Health with the support of development partners. Training of Trainers (Environmental Health

Officers) at districts, hospitals, and Sectors / Health centers are trained to build the capacity of

professionals from lower levels i.e. community based facilitators at cell and village levels. Under

the supervision of the EHOs and health centers, the community based facilitators start CHCs by

The performance of CHCs in transforming sanitation conditions and hygiene behavior

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registering CHC members after a meeting convened by respective heads of villages. The

community based facilitator mobilizes the village members and facilitates the election of CHC

committees for the management and coordination of CHC activities. The community based

facilitator facilitates the dialogue sessions with training materials and tools provided by Ministry

of Health. Throughout the dialogue sessions, CHC members implement recommended practices

in their respective households which are checked along the period by the Community based

facilitator and CHC committee through households’ visits and CHC membership cards for each

of the CHC members representing households. The role of political leadership in supporting

CHC consists of acknowledgement/recognition of the CHC activities, by the leadership,

sensitization of the community on the need of improved sanitation and hygiene practices and

ownership of the CHC activities through reporting system.

Coordination and regulation of Community Health Clubs

At village level, the CHC is coordinated by a CHC committee and a community based facilitator

who facilitates the dialogue sessions. The village leader facilitates and supervises the CHC

activities. At cell level, the Social Economic Development Officer (SEDO) receives monthly

report from CHC committees. The SEDO in turn submits the CHC activity report to the Sector

(in charge of social affairs: ASOC) and Health Centre (Environmental Health Officer). The

Sector and the Health Centre give report on the CHC activities to the District (Health Unit). The

local government supports and supervises the CHC activities and initiatives, organises

competitions between CHCs in the district and offers rewards to the best performing CHC and

best performing home (Model home) at village level.. In terms of legitimacy, both regarding

innovation and governance, the CHC committees are elected under supervision of the village

head and the CHC reports are recognised by the Cell, Sector levels/ Health Centres and the

District. CHCs collaborate with local leaders in their activities and their projects / initiatives,

with local artisans (i.e carpentry and masons). Regarding inclusion and equity, these groups are

voluntary, and group consensus is guiding decision making with mutual assistance to support the

vulnerable.

CHC implantation structure and activities’ monitoring

The community based monitoring can be summarized as shows the figure 1.

The performance of CHCs in transforming sanitation conditions and hygiene behavior

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Ministry of HealthEnvironmental Health Specialist

DistrictDistrict Health Unit (M&E Officer)

)

District Hospital(Environmental Health Officer)

Health Center(Environmental Health Officer)

SectorHealth and Social Affairs

Cell(Social Economic Development Officer)

CHC Facilitator(Village Social Affairs)

Village(Community Health Club)+ Committee

Local organization structure and integration of CHC implementation and monitoring

Adapted from Ministry of Health & Africa AHEAD (2015)

Figure 1: Local organization structure for CHC implementation and monitoring

At community level, the head of the village collaborates with the CHC committee

monitored by the Cell (Social Economic and Development Officer, SEDO), monitored by the

sector level/ ASOC and EHO at Health Center level, monitored by the District/ Health Unit.

Hygiene and sanitation indicators are established from Ministry of Health and used at village /

CHC level through the District (information got from District health units of Kicukiro and

Rusizi). In terms of the content covered through dialogue sessions, songs, drama, slogans and

recommended practices, 20 topics listed in table 1 are completed one topic a session of 1 to 2

Table1. List of topics covered by the CHC members in Rwanda

Starting up a CHC (includes,

Registration of members with cards,

Electing a committee, Naming the

CHC, Health song and slogan and

drama)

Common

Diseases

Personal

Hygiene

Hand Washing Skin

diseases

Diarrhoea Infant Care Worms Food Hygiene Nutrition

Food Security Water Sources Drinking

Water

Sanitation Good

Parenting

Respiratory diseases Malaria Bilharzia village mapping The Model

Home

Source: Adapted from Rwanda Ministry of Health (2011).

Methodology

We conducted a case and control study in Rusizi and Kicukiro which are rural and peri urban

districts respectively. We selected villages and communities in both settings in which CHC

approach was implemented in its all steps and awards given for best practice. From the lists

The performance of CHCs in transforming sanitation conditions and hygiene behavior

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provided by the local health departments, we randomly selected one village/community with

CHC experience (case) and a neighboring control village/community in the same district with no

CHC experience. Both case and control have similar characteristics in terms of water and

sanitation conditions and interventions (Rwanda National Institute of Statistics on integrated

household survey of 2012). Kanyetabi and Kakinyaga communities were selected as a case and a

control in Kicukiro while Nyambeho and Kareba villages were selected as a case and a control in

Rusizi.

We assessed the status of sanitation and hygiene conditions and documented what happened in

the targeted villages between 2012 and 2015 in terms of sanitation and hygiene interventions.

Household surveys, in-depth face-to-face interviews, focus group discussions and spot

observations were used to collect qualitative and quantitative data.

Table 2: Sample size considered from targeted villages

Identification of selected villages Rusizi (rural) Kicukiro(peri urban) Total

Kareba Nyambeho Kakinyaga Kanyetabi,

CHC activities No Yes No Yes

Total number of households 126 110 285 318 839

Sample size (95% of households) 120 105 271 302 798

In total, 798 households (95%) were selected randomly from the list of households provided by

the head of each targeted village/community. In Kicukiro, the case group consisted of 302 and

the control 271 households, while in Rusizi the case group consisted of 105 and the control 120

households. In addition, we conducted in-depth interviews with 2 relevant local leaders, 4

sanitation professionals selected purposively from each of Kicukiro and Rusizi district. 2 focus

group discussions were also conducted in each village/community and the participants of the

focus group discussions were selected from people who responded to the invitation of the village

heads and accepted to participate. One focus group discussion was conducted with opinion

leaders including Community Health Workers and the other with village/community members

only. The documentation focused on sanitation and hygiene conditions and barriers to improving

these conditions, interventions including capacity building, community mobilisation, promotion

activities, funding or any support to households in the targeted villages.

The data collection was performed by environmental health graduates from the department of

environmental health (University of Rwanda) and supervised by 2 Lecturers one per each

targeted district. The data was cleaned and analyzed using SPSS, OpnEpi and ATLAS ti.

Verification and quality control of the data collected was done each day to identify gaps or errors

that were rectified the following day.

Results

Water supply and sanitation characteristics of study Districts and villages

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Table3: Water supply and sanitation status for Rusizi and Kicukiro case and control study

villages/communities (2012).

Characteristi

cs

Rusizi district (rural setting) Kigali City (peri urban setting) Comments

Rusizi

District

Nyambeho

(case study

village)

Kareba

(control

village)

Kicukiro

District

Kanyetabi

Case study

village

Kakinyaga

Control village

Population /

households

550

inhabitants/

110

households

630

inhabitants

/ 126

households

249, 284

inhabitants/

49857

households

1750

inhabitants

/350

households

185

inhabitants

/1425

households

CHC has been

implemented in all

villages of Kicukiro

district that is why

the control is in

Gasabo district -

Ndera Sector close

to Masaka

Access to

improved

water source

67% 25.9% 25.9% 92.7% 90.5% 81.9%

Access to

latrine

96.9% 64.3% 66% 95.4% 15% 20%

Source: National Institute of Statistics of Rwanda (2012) and Heads of villages report (2015)

Table4: Main community empowerment activities in sanitation and hygiene in the study area Rusizi district (rural setting) Kicukiro district (peri urban setting) Comments

Rusizi

District

Nyambeho

(case study

village)

Kareba

(control

village)

Kicukiro

District

Kanyetabi

Case study

village

Kakinyaga

Control

village

CHC for some

villages, PHC

with CHWs,

Monthly

community

work

CHC, PHC

with

CHWs,

Monthly

community

work

PHC with

CHWs,

Monthly

community

work

CHC in all

villages, PHC

with CHWs,

Monthly

community

work

CHC, PHC

with

CHWs,

Monthly

community

work

PHC with

CHWs,

Monthly

community

work

Nyambeho and Kanyetabi

have received CHC

intervention in addition to

the common interventions

comprising PHC with

CHWs and Monthly

community work

Sanitation professionals report (2015), PHC = Primary Health Care

Findings from household surveys and spot observations

Through the household survey, three main barriers of improving sanitation and hygiene

conditions included ignorance, poor water access, and poverty. Poor water access was reported to

be caused by the high cost of water and or the long distance from households to the nearest

water source.

Table 5: Households’ adherence to CHCs

Village Households members of CHC Percent

Nyambeho (rural)

Yes 103 98.1

No 2 1.9

Total 105 100.0

Kanyetabi (peri urban)

Yes 260 86.1

No 42 13.9

Total 302 100.0

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The results show that the CHC model mobilised and involved

98.1% of community members in rural setting and 86.1% in

peri urban setting.

Table 6: Reported barriers to improving sanitation and hygiene conditionss (% of respondents)

Reported

barriers

Rusizi (rural setting) Kigali City (peri urban setting) Kareba, n= 120 Nyambeho, n= 105 Kakinyaga, n= 271 Kanyetabi, n= 302

Ignorance 0.9 0 21 2.6

Poor water access 14.7 93.3 39.9 43.7

Poverty 84.4 0 39.1 53

None 0 6.7 0 0

Total 100 100 100 100

Ignorance about options for improving hygiene and sanitation conditions was reported as a

barrier for improved sanitation at 0.9% and 0% in Kareba and Nyambeho villages respectively

and at 21% and 2.6% in Kakinyaga and Kanyetabi villages respectively. Poor water access is

reported at 14.7% and 93.3% in Kareba and in Nyambeho respectively in Rusizi district while in

Kicukiro, it is reported at 39.9% and 43.7% in Kakinyaga and in Kanyetabi respectively.

Regarding poverty, 84.4% and 0% of respondents in Kareba and in Nyambeho respectively

reported poverty as a barrier in Rusizi while in Kicukiro, the barrier is reported at 39.1% and

53% in Kakinyaga and Kanyetabi respectively.

Table 7: Observed sanitation and hygiene facilities: Case of Rusizi and Kicukiro

Setting Rural (Rusizi district) Peri urban (Kicukiro district)

Villages Nyambeho (n=105) Kareba (=120) Kanyetabi (n=302) Kakinyaga (271)

Sanitation practices 2015 2015 2015 2015

Improved toilet 95.2 14.2 89.4 74.2

Clean toilet 98.1 45 69.5 28

Functional Hand Washing Facility (HWF)

91.4 43.3 74.2 13.7

Soap at HWF 92.4 4.2 38.4 7.7

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Figure 2: Status of sanitation and hygiene in peri urban setting of Kicukiro

Table8. Contribution of CHC approach for improved sanitation and hygiene practices

Practices Rural (p=0.000) Peri urban (p=0.000)

Improved toilet RD=80.24 (95%CI:72.66, 87.81) RD=14.87 (95%CI:8.624, 21.11)

Clean toilet RD=54.05 (95%CI:44.96, 63.14) RD=41.49 (95%CI:34.04, 48.94)

Functional HWF RD=12.6 (95%CI:5.56, 19.64) RD=60.48 (95%CI:54.06, 66.9)

Soap at HWF RD=30.24 (95%CI:24.67, 35.8) RD=30.66 (95%CI:24.32, 37)

Figure 3: Risk difference in households’ sanitation and hygiene practices (%)

Appreciation of CHCs by the heads of villages and community members

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The heads of the two targeted villages are members of CHC (Kanyetabi and Nyambeho) and

testify that they have seen the difference between villages with and without CHC and that 90%

of sanitation and hygiene improvement can be achieved through CHC implementation with

mutual assistance and other initiatives. Community members appreciate the strategies of the

CHC methodology, consisting of village meetings and dialogue sessions, household visits

performed by the community based facilitator and CHC committee, the CHC environment of

love and mutual assistance, songs, dance, drama, demonstrations, applications and commitment.

The community health workers (CHWs) are part of the CHC and appreciate how CHC members

decide together, act together with project initiatives and tangible achievements including but not

limited to making roads, proper nutrition through balanced diet, mutual assistance, saving and

loans and tontine strategies, Kitchen garden, water treatment, as well as being a role model in the

community. The village members of Kakinyaga and Kareba villages not exposed to CHC

activities wish to have CHCs and think their sanitation and hygiene practices would improve

through CHCs.

Community members of the exposed villages confirm CHC implementation facilitated mutual

assistance so that even vulnerable households can have sanitation and hygiene facilities.

Recommended practices allowed households to focus on agreed practices for self esteem and

report. The supportive supervision through visit to households by CHC committee and

facilitators as well as the local leaders and environmental health officers as a form of community

based monitoring influenced households to comply. Savings and loans empowered people

financially and enabled households to access sanitation and hygiene facilities and products like

soap and jerrican for hand washing. “We have been engaged more with CHC and we believe

everything is possible” said the head of village of Nyambeho (Rusizi) and the president of the

CHC committee in Kanyetabi (Kicukiro). Last but not least, during the focus group discussions,

the following was the statement in Rusizi: “we have been always sick but CHC has been a

solution for proper practices including hand washing with water and soap, safe latrine use and

personal hygiene.”

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Motivation / Spirit

• Songs

• Dancing

• Drama

• Supervision

• Competition

knowledge

• Health topics

• Demonstrations • Discussions

• Applications

Group consensus

• Safe practices

• How to achieve• Mutual assistance

• Home visits

CHC Environment

Facilitator, Committee, training module , registration book, membership cards

Beh

avio

r C

hang

e a

nd P

ract

ices

Figure 4: The CHC environment and behavior change factors

Discussion

We investigated the performance of the CHCs in transforming sanitation and hygiene conditions

in different settings. The described characteristics of the CHC implementation from

documentation, interview, and focus group discussions show the CHC approach is totally

community based where the adherence to CHCs is inclusive, voluntary with group consensus

guiding decision making among CHC members and community based monitoring to ensure

accomplishment of recommended practices of households. The CHCs collaborate with local

leaders in their activities / projects / initiatives and local artisans (i.e carpentry and masons)

which is important for sustainability at community level. Through established CHC environment

(dialogue sessions, recommended practices) (figure 4) under the coordination of local leaders

and CHC committees (figure 1), households are able to remarkably improve in sanitation and

hygiene condition. The success of CHC approach has also been reported byLewis (2014) in

Guatemala and the findings of Waterken and Cairncross (2005) in Zimbabwe.

Contribution of CHC approach for improved sanitation and hygiene conditions

This research showed that the implementation of CHC approach has a positive influence on

households’ sanitation and hygiene conditions 4 years after the intervention in Rusizi and

The performance of CHCs in transforming sanitation conditions and hygiene behavior

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Kicukiro. The performance of CHCs in transforming households’ sanitation and hygiene

behaviour and condition is quite good (table7 and figure 3) with some little differences in the

rural and peri urban settings in terms of the extent to which sanitation and hygiene conditions are

increased. These findings show that the CHC approach has the potentials to improve and sustain

sanitation and hygiene conditions in rural and peri urban contexts and fits for contributing to

SDGs 6 that focuses on ensuring availability and sustainable management of water and sanitation

for all (Osborn, Cutter, and Ullah, 2015). Based on the information gathered from focus group

discussions with CHWs and opinion leaders and CHC members from Nyambeho (rural setting)

and Kanyetabi (peri-urban setting), the common response is that CHC approach has helped the

households to improve their sanitation and hygiene conditions. This supports the findings

presented in Table 7 and Figure 3.

The focus group discussions and interviews also revealed a number of factors that help

overcome barriers such as poverty and ignorance (figure 4). These factors include mutual

assistance, joint initiatives, regular meetings / dialogue sessions, household visits performed by

the community based facilitator and CHC committee, slogans, songs, dance, drama,

demonstrations, group consensus, recommended practices and competition. Since the CHC

approach is promoted and supported by the government and consequently by local leaders, there

is a level of community accountability system established and well organized structure (Figure 1)

to support the implementation of CHC approach. Cohen (2014) confirms that community rules

and organizational relationships have influence on peoples’ behavior and practices. Even though

the public health infrastructure is inadequate, at least the sanitation personnel implementing the

approach confirm that learning by doing is integral part of the CHC approach implementation

(Waterkeyn, 2006). The implementation of CHC approach has strengthened communities and

restored natural social network. This social network has been reported by Chavez (2013) to offer

emotional, instrumental, informational and appraisal support for prevention, management and

treatment of diseases. A social ecological perspective of health suggests that social and

environmental factors play an important role in increasing safe practices (Addy et al., 2004),

improve life style practices (Cohen, 2014; Addy et al., 2004, Hernandez & Blazer, 2006 ) with

decreased morbidity (Wilkinson & Pickett, 2011). In the case of CHC approach, 3 main factors

facilitate behavior change of CHC members:

(1) motivation and spirit of action that can be imparted to, according to community members

from the exposed villages, the change process (dialogue sessions, drama, songs, dancing,

competition, supportive supervision, home visits, etc) and the interaction with the

facilitators, supported also by DiClemente (2007).

(2) Knowledge gained from health topics, discussions, demonstrations, and applications

under the name of recommended practices as it has been described by Waterkeyn (2006)

and Waterkeyn & cairncross (2005).

(3) Group consensus which allows community members to adhere and agree on safe

practices (Lewis, 2014), on the way to achieve recommended practices through self-

The performance of CHCs in transforming sanitation conditions and hygiene behavior

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support or mutual assistance with different strategies including saving and loans, income

generation activities and projects, etc.

Similarly with other previous studies, Community Health Club (CHC) Model implementation in

Rusiz and Kicukiro restored and strengthened a diverse natural social networks (Waterkeyn &

Waterkeyn, 2013), increased the availability of social support in natural networks reducing

negative interactions (Lewis, 2014) and promoted self-care at community-level contributing to

the safe practices for health safety (MOUSAVI & ANJOMSHOA, 2014).

Conclusion

CHC approach is dealing with families in an inclusive and equitable way with the consideration

of vulnerable people at village level. The group consensus in decision making, the households

visits, the mutual assistance make CHC approach one of the approaches that can contribute to the

target 6.2 of the SDGs 6 to achieve access to adequate and equitable sanitation and hygiene in

communities. This approach has the potential to end open defecation and address the needs of

women and girls and those in vulnerable situations. In addition CHC approach has the potential

to reach all community members, work with local artisans and local leaders for joint action. In

terms of achievement, leaders and community members claim to have seen the difference

between villages with and without CHC and that 90% improvement of sanitation and hygiene

conditions can be achieved irrespective of barriers. Such testimony needs to be taken into

account since it comes from services beneficiaries not providers.

This research shows that the CHC approach implementation is associated with improvement in

households’ sanitation and hygiene practices 4 years after the intervention in Rusizi (rural

setting) and Kicukiro (peri urban setting). The performance of CHCs in transforming

households’ sanitation conditions and hygiene behaviour is quite good with some little

differences from rural setting and peri urban setting in terms of percentage.

The findings of this research reveal the potentials of the CHC approach to improve sanitation and

hygiene practices in rural and peri urban settings, and contribute to the SDGs in general and

SDGs 6 target 6.2 in particular for sanitation and hygiene. The improvement is supported by a

natural social support network which is restored spontaneously and strengthened by CHC

approach implementation. Based on the structure and the performance of the CHC approach in

other contexts, the Rwanda Ministry of Health adopted the approach in 2010 for nation-wide

implementation with the support of development partners. Further research is needed to assess its

effectiveness compared with other similar approaches and its scalability in different eco socio

economic conditions as per now USAID is supporting CHC implementation in 8 districts in

Rwanda.

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Acknowledgement This research is funded by Vetenskapsrådet through grant number 2013-6364. In Rwanda, we

are grateful for the support of Rwanda Ministry of Health, Ministry of Infrastructure, Water and

Sanitation Corporation (WASAC), FPEAR, the Forum of Water and Sanitation Private Operators,

Unicef, Africa AHEAD and SNV.

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Reference

Addy, C. L., Wilson, D. K., Kirtland, K. A., Ainsworth, B.E., et al. (2004). Associations of

Perceived Social and Physical Environmental Supports with Physical Activity and

Walking Behavior

Anderson, N. B., Bulatao, R. A., and Cohen, B.(2004). Critical Perspectives on Racial and

Ethnic Differences in Health in Late Life.

Cohen, S. (2014). Social Relationships and Health

Ekane, N. (2012). Sanitation Policy and Practice in Rwanda: Tackling the Disconnect

EUFIC. (2014). Motivating Behaviour Change

Hernandez, L. M., and Blazer, D. G. (2006). Genes, Behavior, and the Social Environment:

Moving Beyond the Nature/Nurture Debate

Lewis, K. S. (2014). Community health club and its application for health promotion and

community building in Matazano, Guatemala.

MOUSAVI ,S. M., ANJOMSHOA, M. (2014). Prevention and Control of Non-Communicable

Diseases in Iran: A Window of Opportunity for Policymakers

Nauert, R. (2015). Social Networks and Environment Impact Childhood Obesity

Osborn, D., Cutter, A. and Ullah, F. (2015). UNIVERSAL SUSTAINABLE DEVELOPMENT

GOALS: Understanding the Transformational Challenge for Developed Countries.

REPORT OF A STUDY BY STAKEHOLDER FORUM

Rwanda Ministry of Health (2010). Roadmap of Community Based Environmental Health

Promotion Program

Rychetnik, L., Frommer, M., Hawe, P., Shiell, A. (2002). Criteria for evaluating evidence on

public health interventions

WaterAid .(2011) The sanitation problem: What can and should the health sector do?

Waterkeyn, J. and Cairncross, S. (2005). Creating demand for sanitation and hygiene through

Community Health Clubs: A cost-effective intervention in two districts in Zimbabwe

Waterkeyn. (2006). Cost Effective Health Promotion and Hygiene Behaviour Change through

Community Health Clubs

The performance of CHCs in transforming sanitation conditions and hygiene behavior

Page 16 of 16

Waterkeyn, J. A., & Waterkeyn, A. J. (2013). Creating a culture of health: hygiene behavior

change in community health clubs through knowledge and positive peer pressure.

WHO. (2004). The sanitation challenge: Turning commitment into reality

WHO (2016). Non communicable diseases, fact sheet, updated January 2015

Wilkinson, R., Pickett, K. (2011). The Spirit Level: Why Greater Equality Makes Societies

Stronger

http://benefits.mt.gov/pages/1.files/wellness.health.success.pdf

www.africaahead.com

http://www.ic.ucsc.edu/~rlipsch/Pol272/ Walt.theory.pdf

http://www.medicine.mcgill.ca/epidemiology/courses/655/chapter1.pdf