Poor sanitation and hygiene leads to major diseases, increased public health expenditures, and causes childhood diarrhea, a leading cause of mortality in children under five. In western Rwanda, researchers are evaluating the impact of community hygiene clubs on the health and hygiene of households and on children under five in particular. They are also evaluating the cost-effectiveness of two versions of these clubs to inform Ministry of Health policy as they scale the program nationwide.
Using clean toilets and hand washing with soap prevents the transfer of bacteria, viruses and parasites, which can otherwise contaminate water and food. This contamination is a major cause of diarrhea, the second biggest killer of children in developing countries, and leads to major diseases such as cholera.1 As a locus of information and positive social pressure, community health clubs may be an effective way to change behavior and improve hygiene and sanitation. If they are, the amount of resources necessary to make them effective should be determined. This research contributes rigorous evidence to inform government policy as the Rwandan Ministry of Health scales community health clubs nationwide.
Rwanda has committed itself to reaching ambitious targets in water supply and sanitation, with the vision to attain 100 per cent service coverage by 2020.2 In 2009, the Rwandan government launched the Community Based Environmental Health Promotion Program (CBEHPP), which draws on Africa AHEAD’s community health club model. The purpose of the program is to significantly reduce the national disease burden and contribute to poverty reduction outcomes. Implemented by the Ministry of Health and its water and sanitation partners, CBEHPP aims to strengthen the capacity of approximately 45,000 community social workers, located in 15,000 villages, through the adoption of the Community Hygiene Club (CHC). The goal of the clubs is to generate hygiene behavior changes that are both sustainable and cost effective.3<
To evaluate the health and economic impacts of the CBEHPP on households, and to measure the cost-effectiveness of different versions of the program, researchers will conduct a three-year randomized evaluation among nearly 9,000 households in 150 villages in the district of Rusizi, in western Rwanda.
The 150 villages will be divided into three different groups of 50 villages each:
1.) “Classic” program group: Communities in this study arm will receive the complete CBEHPP program. Highly-trained facilitators – one selected in each village – will lead households through 20 weekly community hygiene club sessions, use high-quality instruction materials, and issue membership cards to participants. At the end of the six-month program, home competitions and a graduation ceremony will take place. Environmental health officers will monitor the clubs and support the club facilitators.
2.) “Lite” program group: Communities in this study arm will receive a two-month program that contains eight weekly sessions covering all the WASH topics. Facilitators selected from each village will receive minimal training and will deliver the topics with black/white photocopies of instructional materials. Membership cards will not be issued and neither will graduation ceremonies or home competitions be held. Environmental Health Officers will provide minimal monitoring of this group.
3.) Comparison group: Communities in this study arm will not receive any program during the study period. (They will receive the Classic program at the conclusion of the study.)
The primary outcomes of interest include diarrhea prevalence, especially among children under age 5; child anthropometrics; household drinking water quality; self-reported disease burden; socio-economic conditions; and cooperation within communities, measured through field-based behavioral games.