Consensus and a Culture of Health: Cost-effective Health Promotion - - PowerPoint PPT Presentation

Consensus and a Culture of Health: Cost-effective Health Promotion through Community Health Clubs

UCT Medical School

7th September, 2006.

• Dr. Juliet Waterkeyn

Presentation plan Slide

4-6 Definition of terms in title 8-10 Changing behaviour related to prevention of diarrhoea 11-17 6 strategies for changing hygiene behaviour 18-20 Results from PHAST Approach in Uganda 21-23 Difference between PHAST and Consensus Approach 25-28 Results from AHEAD Strategy in Zimbabwe 29-34 Decrease in reported cases 35-37 Conclusion and references

This paper demonstrates that … If a ‘Culture of Health’ has been established … by a critical mass of people practicing good hygiene… this behaviour is likely to become permanent… and can reduce communicable diseases.

In Africa we sit under a tree, til we agree.

Julius Nyerere, the first President of Tanzania

C O N S E N S U S

C O M M U N I T Y C O M M ON - U N I T Y

is an active group of members in an area dedicated to developing a Culture of Health in their community by providing a regular forum for learning about disease prevention encouraging safe hygiene practices and providing social support to the vulnerable. thereby addressing the determinants of health A Community Health Club

Norms: habitual behaviour Values: importance attributed to choices Beliefs: interpretation of truth

C U L T U R E

• f

H E A L T H

HABITUAL BEHAVIOUR PATTERNS High risk behaviour:

• Poor home hygiene
• Contaminated food and water
• Open defecation
• Lack of hand-washing with soap

Focus on prevention of Diarrhoea

Objective : to break the Faecal-Oral transmission route

Food Faeces Fred

Fluids

Fields

Flies Fingers

Faecal-Oral Transmission Route

Health Promotion

33%

(Esrey et al)

Safe Sanitation 35%

(Esrey et al 1991)

Hand washing with soap

47 %

(Curtis et al, 2003)

Safe Water 15%

(Esrey et al. 1991) Source: The F Diagramme: PHAST Step-by-step Guide 1998

Previous reviews: a d Esrey SA et al. (1991) Bull WHO 69 (5): 609-621 e Curtis V, Cairncross S (2003) Lancet Inf Dis 3: 275-281.

10 20 30 40 50 60 70

(a) Sanitation (b) Water availability (c) Water quality (d) Hygiene promotion (e) Hand washing

Reduction in diarrhea morbidity (%)

Previous reviews Fewtrell et al. (2004)

Source: Cairncross S, 2005.The Impact of Sanitation. World Bank presentation

% Reduction of Diarrhoea Morbidity by sole Intervention

Can Health and Hygiene Promotion persuade people to change their hygiene behaviour?

Question:

• 2. COGNITIVE – RATIONAL PERSPECTIVE

Appeal to Reason Understanding

• 3. PSYCO-SOCIAL PERSPECTIVE

APPEAL TO Self Respect Collective Shame Status Subliminal approach Self Worth Personal Involvement Group Security Consensus

• 1. SOCIAL PLANNING PERSPECTIVE

Authority

HOW?

Social Planning / Inspection & Control

Government planning, local by-laws Inspecting homes and public outlets Licenses for food stalls, bars, schools Fines for breaking laws People only change when they are forced to do so by authority.

Source: A Waterkeyn.2005. 31st WEDC conference, How to Achieve Sustainable Behaviour change: Busia Example

Health Belief Model

People will improve their hygiene if they know the reason Cognitive-Rational Perspective : APPEAL TO REASON

• House-to-house instruction and research
• School campaigns, health education in curriculum
• Counseling at clinics, anti-natal instruction
• Community Meetings

Photo: Waterkeyn, J. (2004) ACDI/Voca HIV Supplementary Feeding Programme, Uganda

Social Marketing

Psycho-Social Perspective: APPEAL TO STATUS SUBLIMINAL METHOD People are more interested in being smart than healthy

• Advertising on posters
• Flyers and pamphlets
• Radio and TV programs
• Celebrity advertising
• National health days

Source: Curtis et al. (2001) Photo: Matthews B. 2005. Malawi Sanitation Programme

People will change their behaviour out of self respect Psycho-Social Perspective: Collective Shame

Source: Kar, K & Pasteur, K. (2005) Subsidy of Self-Respect? Community Led Total Sanitation. An Update on Recent Developments. IDS Working Papers - 257.

Village walk Village disciplining /fines Public shaming Control by Village Leaders Faecal-oral Demonstration

Community Led Total Sanitation (CLTS)

PHAST

(Participatory Hygiene and Sanitation Transformation) People will change if they participate Psycho-Social Perspective: Personal Involvement

·Village meetings and gatherings

Water and sanitation provision Participatory activities Drama and radio School health clubs Local health days

Source: Srinavasan, L. (1990); WSP-AF /World Bank(1999); PDG (2004)

Consensus Approach (AHEAD Methodology) People change through peer pressure Community Health Clubs PHAST activities Graduation days: public recognition Membership cards provide a structure Psycho- Social Perspective: Group Consensus

Source: Waterkeyn, J and Cairncross, S. (2005)

Weekly health sessions for 6 months

24 observations/reports :

• nly 7 showed significant difference

between intervention and control (p>0.05)

PHAST UGANDA STUDY

Intervention period : 1993-2003 Pop.15,357,429 h/holds = 2,722,236 Cost per beneficiary: US$3 (.49c p.a)

Source: PDG/ WSP-World Bank (2004)

32 districts beneficiaries= 4 million 5 programmes (4 Gov & WaterAid) Total Cost: over US$ 12 million

Proxy indicators of behaviour (p>0.05)

40.4 27 36 57 77.8 77.8 58.8 96.2 45.5 64.3 64.4 84.3 26.6 13.7 37.3 28.8

20 40 60 80 100

No visible w aste in yard Family have ow n latrine Well covered squat hole Well constructed latrine clean latrine handw ashing after defecation Reported use of soap after defec. Average difference all indicators

P ro x y in d ic a to rs % prevalence Control PHAST

BEHAVIOUR CHANGE IN UGANDA: PHAST STUDY

Only 7 out of 24indicators showed significant difference (p >0.05) Average = 13.3%

Source: (PGA, 2004)

Group Consensus

By meeting regularly the group creates: B A shared set of beliefs based on sound knowledge K a common unity of understanding: shared knowledge A Accepted attitudes are developed by the group P Accepted ways of behaviour and hygiene practice

Shared norms and values = A CULTURE OF HEALTH

C O N F O R M I T Y

PhD Syndrome: Pull her Down

as a positive drive

C O N F O R M I T Y

Two Survival Strategies

Behaviouralist Analogy: Carnivores Individualist Past development programmes have made their appeal to people as individuals

FAILURE!

Herbivores Group Safety in numbers

Independent

GROUP APPEAL A dedicated group of people (a Club versus a Gathering) Provide correct information (weekly health sessions) Group decision to endorse change The individual takes less personal risk

Zimbabwe : 2000- 2001

382 health clubs 18,044 members 108,264 beneficiaries

Over 60% of members

• n 20 different health topics

50 recommended practices addressing most preventable diseases completed weekly health sessions 3 districts

• Health Promotion cost 22c per beneficiary

TWO YEAR PROJECT

Health promotion as an entry point

1st YEAR: COMMUNITY COHESION

Knowledge of all communicable diseases Diarrhoea Bilharzia Worm infestations Skin diseases

2nd YEAR: SANITATION PROGRAMME

Eye diseases Malaria Acute respiratory infections HIV/AIDS 1,800 latrines built in 18 months

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% I n d i v i d . C u p s * * * C

• v

e r e d W a t e r * P r

• t

e c t e d w a t e r U s e

• f

l a d l e * * * L a d l e f

• r

W a t e r * * * P

• u

r i n g H w a s h * * * I n d i v i d u a l p l a t e s * * * H a n d W . F . * * * U s e

• f

H W F * * * P

• t

R a c k * * * S w e p t Y a r d * * R u b b i s h P i t * * * W e l l m a n a g e d R . P . * * * N u t r i t i

• n

G a r d e n * * * C a t S a n i t a t i

• n

* * * V I P L a t r i n e * * * C l e a n l a t r i n e * * * U s e d l a t r i n e * * * S

• a

p f

• r

H . w a s h * * *

Club Members Non Members

Dif f erence of Pr evalence of Obser ved Hygiene I ndicat or s bet ween Communit y Healt h Club Member s and non Member s in Tsholot sho Dist r ict , Zimbabwe. 2001

*** p>0.001

Average= 47%

75%

use of I ndividual cups use of a ladle

75% 62%

more pouring

• f water f or

hand washing

57%

Cat Sanitation (covered f aeces)

40%

more VI P Latrines were built

41%

more Nutrition Gardens were made

Difference in behaviour (Tsholotsho District) between health club members & control group

individual plates

76%

78 86 83 74 72 59 74 65 27 25 25 7 22 10 49 51

10 20 30 40 50 60 70 80 90 100

ORS Diarrhoea Malaria Bilharzia Worms Skin TB Child care

non members members

Dif f erence between health club and non health club members in health knowledge

• f preventable diseases (Tsholotsho, 2001)

WARD Year CHCs % CHC h/hold members Ruombwe 1995 18 80% 2,224 1,777 Nyamidzi 1996 13 113% 1,358 1,540 Tanda 1996 14 24% 2,773 677 Tikwiri 1998 6 68% 753 516 Mutanda 1 1998 9 43% 1,186 513 Sangano 1998 10 20% 1,558 309 Dumbamwe 1998 6 78% 936 730 Ngowe 1998 12 56% 2,000 1,123 Weya 1998 15 90% 1,700 1,534 Mutunga 1999 7 78% 947 740 Inyati 2000 5 9% 2,900 253 Totals 96 53% 18,335 9,712 Coverage of Community Health Clubs in Makoni District (1995-2000)

Tikwiri reported cases 1995-2003 500 1000 1500 2000 2500 1995 1996 1997 1998 1999 2000 2001 2002 2003 years # cases Diarrhoea Bilharzia Skin diseases ARI Eye Diseases Malaria

Figure 3. Tikwiri Ward. 1995-2003. Reported cases of communicable diseases

Number of health clubs Period of Health Promotion h/hlds coverage

6 health clubs 1998 - 2001 : 516 68 %

500 1000 1500 2000 2500 3000 1995 1996 1997 1998 1999 2000 2001 2002 2003 Diarrhoea Bilharzia Skin diseases ARI Eye diseases Malaria

Figure 5. Nyamidzi Ward. 1995-2003. Reported cases of communicable diseases

Source: Ministry of Health, Makoni District Hospital, Zimbabwe

Number of health clubs Period of Health Promotion h/hlds coverage

13 health clubs 1996 - 2001 : 1,540 100 %

500 1000 1500 2000 2500 1995 1996 1997 1998 1999 2000 2001 2002 2003 Diarrhoea Bilharzia Skin diseases ARI Eye disease Malaria Source: Ministry of Health, Makoni District Hospital, Zimbabwe

Number Period of Health Promotion h/hlds coverage 18 health clubs 1995 - 2001 1,777 80 % Ruombwe Ward. 1995-2003. Reported cases of communicable diseases

1995 1997 1998 1999 2000 2001 2002 2003 404 301 244 198 166 81 65 26 38 Bilharzia 1310 924 630 673 178 43 45 26 1 685 874 526 364 155 67 90 41 ARI 2136 1422 1684 1286 770 341 251 159 264 277 237 256 124 72 62 87 38 Malaria 318 488 597 548 220 246 243 119 315 Total 5117 4004 3885 2338 1367 823 599 592 208 1,113 1,232 2,779 3,750 4,294 4,518 4,525 1996 Eye dis. Skin dis.

25,198 cases saved

4909 Diarrhoea 1204 1715

Ruombwe Ward. 1995-2003. Reported cases

9 years after the first health clubs were started 25,198 cases saved in Rumbwe ward alone In most of the 20 wards reported cases at Health Centres declined significantly during implementation period (1999 2001) They started to rise slowly thereafter They still remained below 1999 levels

Reported Cases saved in one ward

CONCLUSION The longer health clubs have been active in an area and the higher the density of Community Health Clubs the more there is a likelihood of preventable diseases being significantly and permanently reduced This may be attributable to Health Club activities and positive behaviour change of members

25 Community Health Clubs starting in Khayelitsha

Pre-testing the visual aids for a PHAST activities Thank you for your interest

Health Belief Model: Rogers,E. (1983) Diffusion of Innovation. Effectiveness of Diarrhoea Interventions Esrey SA et al. (1991) Bull WHO 69 (5): 609-621 Curtis V, Cairncross S (2003) Lancet Inf Dis 3: 275-281. Fewrell L & Colford, JM. (2004) Water, Sanitation and Hygiene: Interventions and diarrhoea. A Systematic Review and meta-

• analysis. (HNP) Discussion Paper. Washington.World Bank.

PHAST : WSP-World Bank (2006) PHAST: Experiences from Uganda.

Sanitation and Hygiene Series Field Note Srinavasan, L. (1990) Tools for Community Particiaption. A Manual for Training Trainers in Participatory Techniques. Prowess/UNDP. Tec. Series Involving Women in Water and Sanitation PDG (2004) PHAST Uganda Study. Report for WSP/World Bank

Community Led Total Sanitation. Kar, K. & Pasteur, K. (2005) Subsidy of Self-Respect?

Update on Recent Developments. IDS Working Papers - 257. Social Marketing: Curtis, V., Kanki, B. et al. (2001) Evidence of behaviour change following a hygiene promotion programme in Burkino Faso. Bull WHO (79): 518-527. World Bank-WSP/AF (2002) Hygiene Promotion in Burkina Faso and Zimbabwe: New Approaches to Behaviour Change. Field Note 7: Blue Gold Series.

1999: Structured Participation in Community Health Clubs. 2000: Demand Led Sanitation in Zimbabwe. 2003: Cost-Effective Health Promotion: Community Health Clubs. 2005: Decreasing communicable diseases through improved hygiene in CHCs 2005: Rapid Sanitation uptake in Internally Displaced People Camps N. Uganda through Community Health Clubs 2005: Waterkeyn A. How to Achieve Sustainable Behaviour Change.

2005 Waterkeyn, J and Cairncross, S. No 61. Soc. Sci. & Medicine. Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts of Zimbabwe.

www.lboro/conferences WEDC papers: Waterkeyn et al.

Community Health Club Information www.africaahead.com

2006 Waterkeyn, J. District Health Promotion using the Consensus Approach.

Well / London School of Hygiene and Tropical Medicine