*6.2.3 Rusizi District, Rwanda*

Safe hygiene correlated positively in all but three of the 24 indicators with the number of sessions attended by members (p-value <0.001) (**Figure 5**).

To demonstrate an impact on sanitation in Rwanda was complicated by the fact that four of the indicators did not change significantly simply because, even *before* the start of the intervention, compliance was already exceptionally high - meaning little

improvement could be expected as a result of the CHC training: 91% of households already had their own latrine, 98.5% households showed no child feces, 99.6% showed no adult feces and 90% showed no animal feces in the yard. With this exceptionally high level of latrine ownership, sanitation indicators were altered after the baseline, to an observation of the *hygienic standard* of the open pit latrines, with the recommendation that there should now be a well-fitting foot-operated cover for the squat hole to prevent fly access and breeding. Monitoring data showed a 40% increase in '*having and using a well-fitted cover for the squat hole of latrines'* which increased from 35.5 to 76.5% [46]. The indicator "cover for the squat hole" is the most important indicator of the research, because unlike all other indicators, it was completely unique to the intervention and therefore unlikely to be confounded by previous initiatives [46] (**Figure 4**). This indicator showed that a 41% uptake of covered squat holes may be taken as a proxy indicator of the effect of the CHC on hygiene practice.

Thirteen of the most important indicators showed a significant increase of p > 0.001 (Pearson Chi-Square Asymptomatic Significance) and these are strong indicators of the high level of compliance shown by CHC members in relation to the training: a 5-fold uptake increase from those attending only 1–4 sessions as compared to those who have completed 17–20 sessions [45].

The quality of drinking water has been improved by a combination of improved practices for serving drinking water: 18% more households were making sure that jerry cans used to store drinking water were clean inside (81.9–100%) and that they were closed with lids (from 76.1–95%). A massive rise of 55% in the non-risk practice of the family taking drinking water by *pouring* from a jerry can rather than *dipping* into an open container (34.8–90%) would also decrease risk of contamination of drinking water in the home. The practice of using a (plastic) water filter increased by 24.2% from zero to 24.2% of families who had taken advantage of a district wide distribution of water filters to increase safe water consumption in Rusizi District [45] (**Figure 5**).

Personal hygiene improved slightly with the construction of more bath shelters in yard that increased by 10% (from 34.1 to 44.1%). The construction of a Tippy Tap in the yard increased by 35% (48.3–83.3%) as functional hand washing facility (with soap) were observed, of which 45.3% were situated near latrines. Overall child cleanliness increased enormously with the awareness of the danger of flies spreading Trachoma. The data show 23.1% increase (50–73.21%) in children having clean faces as indicated by no flies on their faces although this gain was not sustained and reverted back to 52.6%. In an increased effort to prevent skin diseases, CHC mothers were washing children's clothes more often. Children with clean clothes on the day of the observation increased by 18% from 63.3 to 81.3% but then dropped to 76.3%, Although this indicator could have been associated with muddier clothes during the wet season [45] it is clear that mothers need continual encouragement to keep their children cleaner (**Figure 5**).

Most importantly for the transmission of germs by the fecal oral route, the 'safe storage of food' improved by 24% from 63.6 to 81.8%, but also recessed later to 71.8% [45] (**Figure 5**).

As regards the prevention of zoonotic diseases, 22% of households (36–58%) had constructed livestock pens away from the kitchen area, and less animal dung was seen in 7% more yards (88.3–90.9%) which were free from animal dung, decreasing further ingestions of germs spread by flies [45] (**Figure 5**).

#### *6.2.4 Qualitative study*

A small qualitative study [47] was also conducted in two CHC Villages in Rusizi District and compared with two non CHC villages to ascertain the perception of the community towards the CHC project.

**49**

Evaluation costs.

*6.3.2 Mberengwa District, Zimbabwe*

*Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community…*

*'They testify to have seen the difference between villages with and without CHC and that 90% of sanitation and hygiene improvement can be achieved through CHC implementation. Community members appreciate the strategies of the CHC approach as it raised spontaneously 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 confirmed CHC implementation facilitated mutual assistance so that even vulnerable households can have sanitation and hygiene facilities. "We have been engaged more with CHC and we believe everything is possible" said the head of village of Nyambeho and the president of the CHC committee in Kanyetabi separately. During the focus group discussions, the following was the statement in Rusizi: "we have been always sick* 

*but CHC has been a solution to prevent hygiene related disease." [47]*

stunting with support from UNICEF and USAID [50].

*6.3.1 Rusizi District, Rwanda*

As the CHC model in CBEHPP was being implemented by around 15 NGOs in Rwanda, there was data from monitoring programs in other Districts such as Bugasera [48] where experience by WaterAid confirmed extensive community response [49] reinforcing much of the positive community feed-back received in Rusizi District. When the disappointing result of the cRCT in Rusizi was presented at the 3rd national CBEHPP Conference in 2017, experienced practitioners of CBEHPP were skeptical of the results as the findings did not tally with other experience of CHC outputs in Rwanda. At the same time the cautious academic conclusion of the cRCT was questioning 'the value of implementing this intervention at scale with the goal of improving health outcomes', the MoH was convinced that the CHC model worked and government was expanding the programmes into the Integrated Nutrition and WASH Program which was to use CHCs in 8 new districts to address

**6.3 Comparative cost-effective analysis of Rusizi and Mberengwa districts**

In Rusizi District, the cost of implementing the cRCT intervention in 50 villages over 12 months amounted to US\$208,204. These costs were for the setting up of the intervention, and interface with the community, with the main activity being the training and monitoring of 50 CHCs. It was a very low budget operation with only a small support staff in the country (one field officer, one monitoring officer in Kigali, a part time programme manager and an accountant) with minimal support of external consultants. With a total of 4056 CHC members in the Classic Villages we calculate 19,096 beneficiaries i.e. family members in the household who have benefited directly from improved living conditions over 50 different indicators. The program is calculated to have cost US\$13.13 per beneficiary or US\$ 61.71 for an average family of 4.7 people. This figure does not include research costs of the cRCT

In Mberengwa District, the cost of the whole programme for 1 year was one fifth less expensive than the Rwandan intervention, at US\$193,529 for a programme of 1 year, which reached five-fold more CHC villages, and with 42,959 beneficiaries

*DOI: http://dx.doi.org/10.5772/intechopen.89995*

*Comparative Assessment of Hygiene Behaviour Change and Cost-Effectiveness of Community… DOI: http://dx.doi.org/10.5772/intechopen.89995*

*'They testify to have seen the difference between villages with and without CHC and that 90% of sanitation and hygiene improvement can be achieved through CHC implementation. Community members appreciate the strategies of the CHC approach as it raised spontaneously 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 confirmed CHC implementation facilitated mutual assistance so that even vulnerable households can have sanitation and hygiene facilities. "We have been engaged more with CHC and we believe everything is possible" said the head of village of Nyambeho and the president of the CHC committee in Kanyetabi separately. During the focus group discussions, the following was the statement in Rusizi: "we have been always sick but CHC has been a solution to prevent hygiene related disease." [47]*

As the CHC model in CBEHPP was being implemented by around 15 NGOs in Rwanda, there was data from monitoring programs in other Districts such as Bugasera [48] where experience by WaterAid confirmed extensive community response [49] reinforcing much of the positive community feed-back received in Rusizi District. When the disappointing result of the cRCT in Rusizi was presented at the 3rd national CBEHPP Conference in 2017, experienced practitioners of CBEHPP were skeptical of the results as the findings did not tally with other experience of CHC outputs in Rwanda. At the same time the cautious academic conclusion of the cRCT was questioning 'the value of implementing this intervention at scale with the goal of improving health outcomes', the MoH was convinced that the CHC model worked and government was expanding the programmes into the Integrated Nutrition and WASH Program which was to use CHCs in 8 new districts to address stunting with support from UNICEF and USAID [50].

#### **6.3 Comparative cost-effective analysis of Rusizi and Mberengwa districts**

#### *6.3.1 Rusizi District, Rwanda*

In Rusizi District, the cost of implementing the cRCT intervention in 50 villages over 12 months amounted to US\$208,204. These costs were for the setting up of the intervention, and interface with the community, with the main activity being the training and monitoring of 50 CHCs. It was a very low budget operation with only a small support staff in the country (one field officer, one monitoring officer in Kigali, a part time programme manager and an accountant) with minimal support of external consultants. With a total of 4056 CHC members in the Classic Villages we calculate 19,096 beneficiaries i.e. family members in the household who have benefited directly from improved living conditions over 50 different indicators. The program is calculated to have cost US\$13.13 per beneficiary or US\$ 61.71 for an average family of 4.7 people. This figure does not include research costs of the cRCT Evaluation costs.

#### *6.3.2 Mberengwa District, Zimbabwe*

In Mberengwa District, the cost of the whole programme for 1 year was one fifth less expensive than the Rwandan intervention, at US\$193,529 for a programme of 1 year, which reached five-fold more CHC villages, and with 42,959 beneficiaries

*Healthcare Access - Regional Overviews*

improvement could be expected as a result of the CHC training: 91% of households already had their own latrine, 98.5% households showed no child feces, 99.6% showed no adult feces and 90% showed no animal feces in the yard. With this exceptionally high level of latrine ownership, sanitation indicators were altered after the baseline, to an observation of the *hygienic standard* of the open pit latrines, with the recommendation that there should now be a well-fitting foot-operated cover for the squat hole to prevent fly access and breeding. Monitoring data showed a 40% increase in '*having and using a well-fitted cover for the squat hole of latrines'* which increased from 35.5 to 76.5% [46]. The indicator "cover for the squat hole" is the most important indicator of the research, because unlike all other indicators, it was completely unique to the intervention and therefore unlikely to be confounded by previous initiatives [46] (**Figure 4**). This indicator showed that a 41% uptake of covered squat holes may be

taken as a proxy indicator of the effect of the CHC on hygiene practice.

pared to those who have completed 17–20 sessions [45].

ment to keep their children cleaner (**Figure 5**).

71.8% [45] (**Figure 5**).

*6.2.4 Qualitative study*

community towards the CHC project.

Thirteen of the most important indicators showed a significant increase of p > 0.001 (Pearson Chi-Square Asymptomatic Significance) and these are strong indicators of the high level of compliance shown by CHC members in relation to the training: a 5-fold uptake increase from those attending only 1–4 sessions as com-

The quality of drinking water has been improved by a combination of improved practices for serving drinking water: 18% more households were making sure that jerry cans used to store drinking water were clean inside (81.9–100%) and that they were closed with lids (from 76.1–95%). A massive rise of 55% in the non-risk practice of the family taking drinking water by *pouring* from a jerry can rather than *dipping* into an open container (34.8–90%) would also decrease risk of contamination of drinking water in the home. The practice of using a (plastic) water filter increased by 24.2% from zero to 24.2% of families who had taken advantage of a district wide distribution of water filters to increase safe water consumption in Rusizi District [45] (**Figure 5**). Personal hygiene improved slightly with the construction of more bath shelters in yard that increased by 10% (from 34.1 to 44.1%). The construction of a Tippy Tap in the yard increased by 35% (48.3–83.3%) as functional hand washing facility (with soap) were observed, of which 45.3% were situated near latrines. Overall child cleanliness increased enormously with the awareness of the danger of flies spreading Trachoma. The data show 23.1% increase (50–73.21%) in children having clean faces as indicated by no flies on their faces although this gain was not sustained and reverted back to 52.6%. In an increased effort to prevent skin diseases, CHC mothers were washing children's clothes more often. Children with clean clothes on the day of the observation increased by 18% from 63.3 to 81.3% but then dropped to 76.3%, Although this indicator could have been associated with muddier clothes during the wet season [45] it is clear that mothers need continual encourage-

Most importantly for the transmission of germs by the fecal oral route, the 'safe storage of food' improved by 24% from 63.6 to 81.8%, but also recessed later to

As regards the prevention of zoonotic diseases, 22% of households (36–58%) had constructed livestock pens away from the kitchen area, and less animal dung was seen in 7% more yards (88.3–90.9%) which were free from animal dung, decreasing further ingestions of germs spread by flies [45] (**Figure 5**).

A small qualitative study [47] was also conducted in two CHC Villages in Rusizi District and compared with two non CHC villages to ascertain the perception of the

**48**

had twice as many beneficiaries as Rwanda. The costs included the operational support for 6 field officers and a programme manager, with part time administrative costs for the organization headquarters in Harare, and a shared office in the field. The program is estimated at only US\$4.5 per beneficiary, or US\$22 per household.
