Community Health Clubs (CHC) 50 50 243 237 Average # of members/CHC 81 70 40 34.6 # households in all villages 6942 n/a 8208 n/a Mean of family in a household 4.7 n/a 4.4 n/a # CHC members in all CHCs 4056 5000 9615 8208 Ratio female: male members in CHC 58:42 60:40 80:20 60:40 % of CHC coverage in a village 63% 80% 117% 100% Number beneficiaries (family) 19,063 23,500 42,595 36,115 # NGO field officers in field 1 1 6 6 # Motor bikes for NGO field officer 0 2 6 6 # Environmental Health Officers 10 50% 3 6 # Motorbikes for MoH 5 50% 0 0% # Weeks of training 16 24 24 24 # Health sessions held in all CHC 718 1200 4860 4860 Mean # health sessions / CHC 14.5 24 20 24

**Rusizi, Rwanda Mberengwa, Zimbabwe**

41 50% 26 34

**Actual achieved** **Expected target**

**Expected target**

selected for the intervention as it was one of the least developed areas of Rwanda with one of the highest levels of diarrhea and stunting in the country. There were 79,880 households in 596 villages with a total population of 375,436. Most of the population are subsistence farmers or fisherman with some trading across the nearby border to Burundi and the Democratic Republic of Congo [37]. The total population for the 50 Classic villages was 32,313 people within 6866 households, with an average of 646 people and 137 households per village, and an average of 4.7 people per household. Literacy is 73% for men and women over the age of 15 [38]. Rusizi has a tropical climate and rainforest with heavy annual rainfall of over

*Comparative summary of community mobilization of 50 classic villages in Rusizi District, Rwanda in 2014* 

Literacy level women (men) 73% n/a 80 (85%) 80% # (%) of CHC members graduating 1703 42.4% 6335 (77%) 8208 Cost of Project (field costs only) US\$ 250,325 n/a 193,529 n/a Cost in US\$ per beneficiary 13.13 5 4.5 5 Cost in US\$ per family 61.71 25 22 25

The start-up of the CHC intervention was delayed by 6 months whilst the baseline

and randomization of villages was being completed. By November 50 CHCs were formed (**Table 1**)*,* one in each intervention village. The engagement of village leaders in the start-up was neglected due to difficulty with transport as the short rains had already just begun, making many villages inaccessible in tropical mountainous terrain. Nevertheless, the intervention was expected to continue despite the season, and facilitators were selected and trained in February 2014. Training took place from March to June during the long rains, and the period was curtailed to 5 months when

1400 mm per annum, with most falling between February and May.

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

Mean attendance of members /CHC /

*with 243 classic CHCs in Mberengwa District, Zimbabwe in 2012.*

session

**Table 1.**

**Mobilization targets Actual** 


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

#### **Table 1.**

*Healthcare Access - Regional Overviews*

(FAN) in the two subsequent years.

households were within in a CHC.

to coordinate the sector as has been so effectively done in Rwanda. In Zimbabwe, NGOs are largely coordinated through UNICEF which heads the WASH Cluster. Zimbabwe AHEAD (ZA) partnered with Action Contre la Faim (ACF) to implement the Public Health Promotion and Community Livelihoods Improvement Program in Gutu and Mberengwa Districts [9]. Midlands Province is one of the most arid areas of Zimbabwe with a low rainfall of 150–250 mm. Literacy is over 80% for both men and women. ZA was responsible for the 'software' (meaning mobilization and training of people) in Stage 1 (Health Promotion), whilst ACF managed the implementation of the 'hardware' component (i.e. infrastructure) for the Stage 2 (Water and Sanitation) and Stage 3 (Food, Agriculture & Nutrition)

The main task for ZA was to mobilize the community and to start up and train CHCs, in order to promote full community participation and inculcate increased responsibility to ensure strong community ownership for the water provision programme. Most people in the area are subsistence farmers, but as many men are away from home all year working in South Africa, their wives remain to run their farms. The year 2012 was not an enabling period in which to run a program in a remote rural area, as the economy had collapsed with hyperinflation, political tensions were high, and Zimbabwe had dropped to the 14th lowest in Human Development Index in the world [36] with a critical scarcity of fuel, banknotes and electricity. Stage 1 of the program ran for 24 months, from February 2012 to January 2014. This was a well-staffed programme with 6 field officers stationed across 8 wards, supervised by a programme manager based in the District Office (**Table 1**)*.* The aim was to achieve blanket coverage of households in these wards, so that all available

Unlike other CHC programmes where CHCs have around 100 members, ACF was adamant that to ensure better quality of training, the size of the CHC membership should be restricted to between 40 and 50 members in each CHC. Therefore, to enable the whole village to join, a second CHC would be formed if there was enough demand from the community. In fact, such was the popularity of the CHCs that the target of 8208 possible members was exceeded with a total of 9615 members registered resulting in universal coverage within 2 years (**Table 1**)*.* To achieve more gender balance, it was strongly advocated by the project officers in mobilizing the community, that the CHC was not only a woman's concern, but that husbands as well as wives should be members. As a result, there were 1196 male CHC members (18% of the total membership), resulting in 1407 households where both husband and wife attended the CHC together. Blanket coverage was achieved with the total number of members being 17% more than number of households. As for compliance with training, with sufficient time and personnel, all of the CHCs managed to complete the required number of 20 training sessions, with 4864 sessions being held in total. Mberengwa had an exceptional completion rate, with 77% of CHC members graduating with full attendance, which is higher than many other CHCs project in Zimbabwe. Ministry of Health had three Environmental Health Technicians (EHTs) stationed in the project area who were meant to be involved in the programme but had no transport: they relied on the NGO which effectively managed the program, with all field officers having their own motorbike. To understand the scale of the project, mobilization details can be compared between Mberengwa in Zimbabwe and Rusizi

In 2012, a cluster Randomized Controlled Trial (cRCT) was proposed to establish the cost-effective of the CHC model within CBEHPP. Rusizi District was

**36**

in Rwanda (**Table 1**)*.*

**4.2 Rwanda: Rusizi District**

*Comparative summary of community mobilization of 50 classic villages in Rusizi District, Rwanda in 2014 with 243 classic CHCs in Mberengwa District, Zimbabwe in 2012.*

selected for the intervention as it was one of the least developed areas of Rwanda with one of the highest levels of diarrhea and stunting in the country. There were 79,880 households in 596 villages with a total population of 375,436. Most of the population are subsistence farmers or fisherman with some trading across the nearby border to Burundi and the Democratic Republic of Congo [37]. The total population for the 50 Classic villages was 32,313 people within 6866 households, with an average of 646 people and 137 households per village, and an average of 4.7 people per household. Literacy is 73% for men and women over the age of 15 [38]. Rusizi has a tropical climate and rainforest with heavy annual rainfall of over 1400 mm per annum, with most falling between February and May.

The start-up of the CHC intervention was delayed by 6 months whilst the baseline and randomization of villages was being completed. By November 50 CHCs were formed (**Table 1**)*,* one in each intervention village. The engagement of village leaders in the start-up was neglected due to difficulty with transport as the short rains had already just begun, making many villages inaccessible in tropical mountainous terrain. Nevertheless, the intervention was expected to continue despite the season, and facilitators were selected and trained in February 2014. Training took place from March to June during the long rains, and the period was curtailed to 5 months when

the intervention had to wind up activities according to the research protocol. For a full one year after the training ended (July 2014 to June 2015), the cRCT permitted no follow up by project implementation staff: there was no opportunity for revision of sessions, no model home competitions and very few graduations held as promised to reward those who had completed the training. After this year, without any external support to the community, the post intervention survey for the cRCT was undertaken. It was estimated that the intervention had only a 54% fidelity to protocol [30].

Of the possible 6942 households in the 50 villages, 4056 were enrolled in CHCs (50.7%) and of these 3144 CHC members (62.8%) attended weekly sessions with 42.4% competing all 20 sessions. Due to shortage of training period, and lack of monitoring and supervision by Ministry of Health, only 10 CHC came near to meeting mobilization targets: 76% had over 100 CHC members, only 50% reached over 80% coverage of households in a CHC in 1 year. Only 6% of CHC met the required target of providing 20 sessions of training within the intervention period—the mean being 14 meetings. The average attendance of all registered members at CHC sessions was 41 members per meeting. Although the 10 Environmental Health Officers had been expected to implement the intervention, they were grounded with no transport for the duration of the project. Africa AHEAD had only one monitoring officer but she did not have a dedicated vehicle, having to hire a motorbike taxi to monitor the whole district of 960 sq.km of challenging terrain during the heavy rains [30].

#### **4.3 Methodology of training in a community health Club**

The CHC methodology of training in both Zimbabwe and Rwanda is considered to be the 'Classic' CHC training (**Table 2**): although the CBEHPP Manual [40] was adapted to the Rwandan context, it was based on the original manual produced by the architects of the approach in Zimbabwe in 2009 [39]. In both countries CHC facilitators are given visual aids known as a 'Tool Kit" of illustrated A5 cards, which help to stimulate discussion in a variety of activities. CHC facilitators are usually nominated by the village leader from each village. They are voluntary and do not receive any financial incentives for the time they give the community although they receive basic equipment (a T-shirt, hat, boots, rucksack, raincoat and possibly a bicycle). CHC Facilitators are then trained by Ministry of Health extension staff or by the implementing NGO in a five-day training workshop, during which they acquire participatory facilitation skills as well as learning the transmission routes and basic information about prevention of common diseases addressed in the various sessions When the facilitator returns to the village she registers as many members as possible to form up a CHC with a member from every household in the village and issues each member with a membership card (See CHC. **Figure 1**).

A health club can be compared to a religious group or a Scout meeting which assembles regular members together every week for a couple of hours. With a program to address local health and hygiene challenges, the regular opportunity to gather provides much team-building with songs and slogans that help to reinforce the knowledge which is gained through the 'dialogue sessions'. Much use is made of key messages in visual aids, as well as being acted out in drama and role play. 'Participatory activities' such as the '*Three pile sorting'*, or '*Blocking the Route'* activity are used to engage members. These games were originally developed to engage community in the 'Participatory Hygiene and Sanitation Transformation' (PHAST) training methodology for the maintenance of water and sanitation facilities [26].

The CHC aims to produce a cohesive community where there is genuine 'common-unity' of understanding, belief and practice. The group itself makes the rules which influence individual behavior and practices similar to the iterative process of peer learning pioneered in the education sector [41]. Each topic focuses on a *single*

**39**

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

**classic**

Yes Partially

Yes Partially

Yes 10 EHOs but no transport

No. Only 1 PO

season

Yes Not all CHCs had graduation

Yes Only 10% of CHC

reached 80%

Yes Yes

Yes. 10x POs

**Rwanda classic**

**Key components of a classic CHC intervention Zimbabwe** 

 Politically enabling environment through a national policy Yes Yes A CHC Manual, customized to national conditions Yes Yes A tool kit of culturally appropriate visual aids Yes Yes All sessions are participatory/dialog not didactic Yes Yes 24 × 2 h participatory sessions are provided Yes Partially

9 All CHC facilitators have a thorough 5 day training Yes Yes

13 All members have a membership card signed on attendance Yes Yes

15 Monitor with household inventory at base and end line Yes Yes

17 There is no material subsidy for water/sanitation Yes Yes 18 CHCs aim to have 50–100 members who are registered Yes Yes 19 CHCs aim to have >50% members complete all 24 sessions Yes Yes

*Specifications for a Classic CHC Intervention, showing fidelity to protocol in Zimbabwe and Rwanda* 

16 Model Home Competitions held at the end of training Yes No, none held

12 24 session last for 6 consecutive months in dry season Yes 4–5 months in wet

aspect of hygiene, with a *single* activity recommended as homework, which does not incur much cost for the household (e.g. covering stored drinking water, constructing a pot rack). Incremental change is seen gradually over time, but it is our belief that at least 24 sessions over 6 months are needed to be sure that knowledge and

CHC members receive no material incentives or food for attending health sessions, and the lack of "hand-outs" is made clear at the start of the program, ensuring that there are no false expectations of material gain. Despite this lack of material incentive, CHCs invariably attract a consistently high attendance rate at health sessions over an extended period, and there has seldom been any difficulty attracting a large crowd of 50–100 people in the many projects discussed above. A membership card is given to each member when they join the club (**Figure 1**). This card gives confidence to members that the facilitators will provide the specified number of sessions, so providing a psychological guarantee that the training will, in fact, be completed. Members appear to value their membership cards highly

practice are sufficiently reinforced (**Figure 1**)*.*

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

supportive/funded directly

practice

Worker

facilitator

attendance

80%

**Table 2.**

*interventions.*

MoH monitoring

1 District Ministry of Health (MoH) is fully involved/

7 One topic per session with a recommended preventive

8 CHC Facilitator is local volunteer/Community Health

10 Environmental Health Officers monitor CHC and assist

11 Enough dedicated NGO Project Officers (PO) supports

14 A certificate is awarded at a graduation ceremony for full

20 Household Coverage of CHCs in a village should be over

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


#### **Table 2.**

*Healthcare Access - Regional Overviews*

the intervention had to wind up activities according to the research protocol. For a full one year after the training ended (July 2014 to June 2015), the cRCT permitted no follow up by project implementation staff: there was no opportunity for revision of sessions, no model home competitions and very few graduations held as promised to reward those who had completed the training. After this year, without any external support to the community, the post intervention survey for the cRCT was undertaken.

It was estimated that the intervention had only a 54% fidelity to protocol [30].

**4.3 Methodology of training in a community health Club**

Of the possible 6942 households in the 50 villages, 4056 were enrolled in CHCs (50.7%) and of these 3144 CHC members (62.8%) attended weekly sessions with 42.4% competing all 20 sessions. Due to shortage of training period, and lack of monitoring and supervision by Ministry of Health, only 10 CHC came near to meeting mobilization targets: 76% had over 100 CHC members, only 50% reached over 80% coverage of households in a CHC in 1 year. Only 6% of CHC met the required target of providing 20 sessions of training within the intervention period—the mean being 14 meetings. The average attendance of all registered members at CHC sessions was 41 members per meeting. Although the 10 Environmental Health Officers had been expected to implement the intervention, they were grounded with no transport for the duration of the project. Africa AHEAD had only one monitoring officer but she did not have a dedicated vehicle, having to hire a motorbike taxi to monitor the whole district of 960 sq.km of challenging terrain during the heavy rains [30].

The CHC methodology of training in both Zimbabwe and Rwanda is considered to be the 'Classic' CHC training (**Table 2**): although the CBEHPP Manual [40] was adapted to the Rwandan context, it was based on the original manual produced by the architects of the approach in Zimbabwe in 2009 [39]. In both countries CHC facilitators are given visual aids known as a 'Tool Kit" of illustrated A5 cards, which help to stimulate discussion in a variety of activities. CHC facilitators are usually nominated by the village leader from each village. They are voluntary and do not receive any financial incentives for the time they give the community although they receive basic equipment (a T-shirt, hat, boots, rucksack, raincoat and possibly a bicycle). CHC Facilitators are then trained by Ministry of Health extension staff or by the implementing NGO in a five-day training workshop, during which they acquire participatory facilitation skills as well as learning the transmission routes and basic information about prevention of common diseases addressed in the various sessions When the facilitator returns to the village she registers as many members as possible to form up a CHC with a member from every household in the village and issues each member with a membership card (See CHC. **Figure 1**). A health club can be compared to a religious group or a Scout meeting which assembles regular members together every week for a couple of hours. With a program to address local health and hygiene challenges, the regular opportunity to gather provides much team-building with songs and slogans that help to reinforce the knowledge which is gained through the 'dialogue sessions'. Much use is made of key messages in visual aids, as well as being acted out in drama and role play. 'Participatory activities' such as the '*Three pile sorting'*, or '*Blocking the Route'* activity are used to engage members. These games were originally developed to engage community in the 'Participatory Hygiene and Sanitation Transformation' (PHAST) training methodology for the maintenance of water and sanitation facilities [26]. The CHC aims to produce a cohesive community where there is genuine 'common-unity' of understanding, belief and practice. The group itself makes the rules which influence individual behavior and practices similar to the iterative process of peer learning pioneered in the education sector [41]. Each topic focuses on a *single*

**38**

*Specifications for a Classic CHC Intervention, showing fidelity to protocol in Zimbabwe and Rwanda interventions.*

aspect of hygiene, with a *single* activity recommended as homework, which does not incur much cost for the household (e.g. covering stored drinking water, constructing a pot rack). Incremental change is seen gradually over time, but it is our belief that at least 24 sessions over 6 months are needed to be sure that knowledge and practice are sufficiently reinforced (**Figure 1**)*.*

CHC members receive no material incentives or food for attending health sessions, and the lack of "hand-outs" is made clear at the start of the program, ensuring that there are no false expectations of material gain. Despite this lack of material incentive, CHCs invariably attract a consistently high attendance rate at health sessions over an extended period, and there has seldom been any difficulty attracting a large crowd of 50–100 people in the many projects discussed above.

A membership card is given to each member when they join the club (**Figure 1**). This card gives confidence to members that the facilitators will provide the specified number of sessions, so providing a psychological guarantee that the training will, in fact, be completed. Members appear to value their membership cards highly


#### **Figure 1.**

*Inside of a typical membership card showing topics and homework for each session.*

keeping them carefully wrapped in plastic at home like their cards from a clinic. They enjoy the challenge of completing their cards, by attending all sessions [8]. They are then rewarded with a certificate, and this aspect of the CHC model may be the key to high attendance rates.

Seeking to understand the popularity of the CHCs, we found from interviewing CHC members in Zimbabwe that the principle attraction of CHCs, is their perceived need for knowledge, especially related to the health and wellbeing of their family. This love of learning appears to be one of the principle drivers of the CHC Model [8].

#### **4.4 Context of the two interventions**

The key components for a CHC intervention were very similar in both Rusizi and Mberengwa, aiming to meet all the specifications for the 'Classic' CHC Training (**Table 2**)*.* In both interventions the key messages in 24 topics on the Membership Card were similar and local villagers were used as community-based facilitators to run the weekly health sessions, whilst Environmental Health Staff were expected to help *monitor* the intervention whereas in Rusizi they were meant to *implement* the program. An important difference between Zimbabwe and Rwanda, is that whereas the Mberengwa project was *community-led* and could expand to respond to the demands of the CHC members, being unconstrained by programme length or design, the Rwandan programme in the Rusizi trial was tightly controlled by the *research* protocol and had no flexibility to adjust timing or scope as the end line survey had to be completed before registered toddlers grew out of the cohort.

Hygiene and sanitation standards between the two countries vary considerably. In Zimbabwe the Government recommended standard for sanitation is a Blair Ventilated Improved Pit (BVIP) latrine which usually has brick lined pit with

**41**

levels of excellence.

uptake is still relatively low.

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

cement slab, whilst the superstructure is likely to be permanent constructed in bricks, often plastered with cement with a tin roof and vent pipe with a fly gauze at

For many years the building of BVIP latrines for the community was extensively

the top to trap flies, thereby preventing breeding, as well as reducing smell.

subsidized by NGOs in WASH programs in Zimbabwe, but with the political turmoil and resultant socio-economic collapse of the country in 2000 when most donors withdrew, there has been little sanitation subsidy. As a result, the high coverage of improved sanitation which climbed rapidly during the 1990's and reached over 63% by 2000, had, a decade later, plummeted to around 25% in most areas, with a return to much open defecation [42]. Without such support, householders tended to build temporary latrines until they could afford the better standard of a BVIP. Instead of a brick wall and tin roof householders would sometimes use traditional mud and pole for walls with a thatch roof to save costs, but invest in lining the pit, having a cement slab and most importantly a vent pipe as is shown in **Figure 2** above. Research shows that it is the cost of a BVIP that prevents quicker uptake, but that with time CHC members do aim for this high government standard [43]. If they cannot afford to construct a proper latrine, CHC members are encouraged to practice 'cat sanitation' (i.e. the burial of their feces in a hole). This simple method is in fact more hygienic than an uncovered pit latrine which can add to the spread of diarrhea by becoming a breeding site for flies. A hand washing station known as a 'Tippy tap' is common practice in Zimbabwe, made from a jerrycan strung from

local branches with a foot operated method for tipping out water.

In Rwanda, over 90% of households have their own latrine and there is little defecation in the surrounding bush [30]. The superstructure is usually made of mud/pole walls and thatch roof. The norm is an unlined pit latrine, with poorly fitting logs with gaps between them, straddling the pit and the smell is always unpleasant and there are frequently feces on the floor (See **Figure 2**)*.* As the pit is not properly sealed flies breed in great numbers and the pits are often thick with maggots making this method highly unsanitary. This could be called 'fixed point open defecation' as it is no more sanitary than open defecation on the ground. The level of handwashing with soap is extremely low in Rwanda, and there are seldom handwashing facilities outside such latrines although most households have soap and wash hands in a common bowl before eating. Zimbabwean households usually have a dedicated kitchen with an open fireplace in the centre of the round thatched cooking hut. Seating for men is a molded bench around the walls, whilst women and children sit on the ground by the fire, and chickens enter freely. The hut is usually very smoky causing a high rate of acute respiratory infections (See **Figure 2**)*.* Traditionally, cooking huts were highly decorated with built-in clay shelving in the walls and this practice has been reinvigorated by the CHCs with all members upgrading their kitchens in ever increasing

Water is stored in well covered containers and food is kept in containers to protect from flies and rodents. Many now use fuel-efficient stoves built in clay, and have seats for women on a par with men, thus showing increased gender equity. All food and utensils are stored in this kitchen hut which is kept locked (**Figure 3**). Cooking in Rwanda, as in many East African countries, is done outside on an open fire (**Figure 3**)*.* There is no culture of a dedicated kitchen hut as in Zimbabwe, and therefore the storage of utensils is haphazard, with no special place to store cooking pots, plates or food. Sometimes this is kept in the main house in boxes or baskets but almost always open to vermin. There is usually a shelter outside where goats are tied and this often doubles to provide shelter for cooking in the rains. Water is collected in a jerry can and stored unsystematically often without a cover. Filtration of water and fuel-efficient stoves are being promoted by government but

*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*

cement slab, whilst the superstructure is likely to be permanent constructed in bricks, often plastered with cement with a tin roof and vent pipe with a fly gauze at the top to trap flies, thereby preventing breeding, as well as reducing smell.

For many years the building of BVIP latrines for the community was extensively subsidized by NGOs in WASH programs in Zimbabwe, but with the political turmoil and resultant socio-economic collapse of the country in 2000 when most donors withdrew, there has been little sanitation subsidy. As a result, the high coverage of improved sanitation which climbed rapidly during the 1990's and reached over 63% by 2000, had, a decade later, plummeted to around 25% in most areas, with a return to much open defecation [42]. Without such support, householders tended to build temporary latrines until they could afford the better standard of a BVIP. Instead of a brick wall and tin roof householders would sometimes use traditional mud and pole for walls with a thatch roof to save costs, but invest in lining the pit, having a cement slab and most importantly a vent pipe as is shown in **Figure 2** above. Research shows that it is the cost of a BVIP that prevents quicker uptake, but that with time CHC members do aim for this high government standard [43]. If they cannot afford to construct a proper latrine, CHC members are encouraged to practice 'cat sanitation' (i.e. the burial of their feces in a hole). This simple method is in fact more hygienic than an uncovered pit latrine which can add to the spread of diarrhea by becoming a breeding site for flies. A hand washing station known as a 'Tippy tap' is common practice in Zimbabwe, made from a jerrycan strung from local branches with a foot operated method for tipping out water.

In Rwanda, over 90% of households have their own latrine and there is little defecation in the surrounding bush [30]. The superstructure is usually made of mud/pole walls and thatch roof. The norm is an unlined pit latrine, with poorly fitting logs with gaps between them, straddling the pit and the smell is always unpleasant and there are frequently feces on the floor (See **Figure 2**)*.* As the pit is not properly sealed flies breed in great numbers and the pits are often thick with maggots making this method highly unsanitary. This could be called 'fixed point open defecation' as it is no more sanitary than open defecation on the ground. The level of handwashing with soap is extremely low in Rwanda, and there are seldom handwashing facilities outside such latrines although most households have soap and wash hands in a common bowl before eating.

Zimbabwean households usually have a dedicated kitchen with an open fireplace in the centre of the round thatched cooking hut. Seating for men is a molded bench around the walls, whilst women and children sit on the ground by the fire, and chickens enter freely. The hut is usually very smoky causing a high rate of acute respiratory infections (See **Figure 2**)*.* Traditionally, cooking huts were highly decorated with built-in clay shelving in the walls and this practice has been reinvigorated by the CHCs with all members upgrading their kitchens in ever increasing levels of excellence.

Water is stored in well covered containers and food is kept in containers to protect from flies and rodents. Many now use fuel-efficient stoves built in clay, and have seats for women on a par with men, thus showing increased gender equity. All food and utensils are stored in this kitchen hut which is kept locked (**Figure 3**).

Cooking in Rwanda, as in many East African countries, is done outside on an open fire (**Figure 3**)*.* There is no culture of a dedicated kitchen hut as in Zimbabwe, and therefore the storage of utensils is haphazard, with no special place to store cooking pots, plates or food. Sometimes this is kept in the main house in boxes or baskets but almost always open to vermin. There is usually a shelter outside where goats are tied and this often doubles to provide shelter for cooking in the rains. Water is collected in a jerry can and stored unsystematically often without a cover. Filtration of water and fuel-efficient stoves are being promoted by government but uptake is still relatively low.

*Healthcare Access - Regional Overviews*

the key to high attendance rates.

**Figure 1.**

**4.4 Context of the two interventions**

keeping them carefully wrapped in plastic at home like their cards from a clinic. They enjoy the challenge of completing their cards, by attending all sessions [8]. They are then rewarded with a certificate, and this aspect of the CHC model may be

*Inside of a typical membership card showing topics and homework for each session.*

Seeking to understand the popularity of the CHCs, we found from interviewing CHC members in Zimbabwe that the principle attraction of CHCs, is their perceived need for knowledge, especially related to the health and wellbeing of their family. This love of learning appears to be one of the principle drivers of the CHC Model [8].

The key components for a CHC intervention were very similar in both Rusizi and Mberengwa, aiming to meet all the specifications for the 'Classic' CHC Training (**Table 2**)*.* In both interventions the key messages in 24 topics on the Membership Card were similar and local villagers were used as community-based facilitators to run the weekly health sessions, whilst Environmental Health Staff were expected to help *monitor* the intervention whereas in Rusizi they were meant to *implement* the program. An important difference between Zimbabwe and Rwanda, is that whereas the Mberengwa project was *community-led* and could expand to respond to the demands of the CHC members, being unconstrained by programme length or design, the Rwandan programme in the Rusizi trial was tightly controlled by the *research* protocol and had no flexibility to adjust timing or scope as the end line survey had to be completed before registered toddlers grew out of the cohort. Hygiene and sanitation standards between the two countries vary considerably. In Zimbabwe the Government recommended standard for sanitation is a Blair Ventilated Improved Pit (BVIP) latrine which usually has brick lined pit with

**40**

#### **Figure 2.**

*Left: Subsidized ventilated improved pit latrine (VIP) in a CHC home in Zimbabwe with lined pit, concrete slab and vent pipe - a fly trap which eliminates smell and a hand washing facility. Right: An unsubsidized traditional pit latrine in Rwanda, unlined and open pit, log floor giving open access for flies. Photographs courtesy of J. Waterkeyn.*

#### **Figure 3.**

*Left: A model CHC kitchen hut in Zimbabwe showing shelving made of clay, individual family utensils and covered drinking water with ladle. Right: In Rwanda, a traditional cooking shelter outside, with no CHC improvements. Photographs courtesy of J. Waterkeyn.*
