Best Practice in Health Promotion - Africa AHEAD

Best Practice in Health Promotion - Africa AHEAD

CHC and CLTS: How can they be integrated? Dr. Juliet Waterkeyn, UNC Conference: CHC seminar. Nov. 2012 A Model of Development is one that can be used to explain: 1. Why people are galvanised into action. 2. Predict the conditions under which such action will occur. 3. It should also demonstrate the relationship between knowledge, belief, social norms and behaviour.

A MODEL IS THE VISUALISATION OF A THEORY WHICH IS BASED ON ASSUMPTIONS FORMED BY: Direct experience and observation Indirect sources: read or been told by people or trusted sources(Head man). For example: To get people to change they need to be shamed into good behaviour. People change behaviour because they want to improve their childrens chances of survival. Both target the community as a Group

Both Community Led CLTS through village CHC through village Approaches Traditional Leaders women CHC Chairwoman SANITATION CONSCIOUSNESS & NO SUBSIDY Open Defecation Free area = Zero Open Defecation (ZOD) No subsidy: develop Self reliance and Dignity: No need for

charity handouts Basic Assumption of Classic CLTS: Negative peer pressure People will change if they are shamed into good behaviour i.e. Naming and Shaming Conservative and Authoritarian The training manual for CLTS (Kar) advises the key is standing in the OD area, inhaling the unpleasant smell and taking in the unpleasant sights of shit lying all over the place. If people try to move you on, insist on staying there despite their embarrassment. Experiencing the disgusting sight and smell in this new collective way, accompanied by a visitor to the community is the key trigger for mobilisation.

The handbook for CLTS cites unabashedly a successful case study: In the districts of NW Bangladesh, children were known as bichu bahini the army of scorpions. They were given whistles and went out looking for people doing OD. One youth said that during the campaign for ODF he had blown his whistle at least 60 times. In a few cases they carried out goo jhanda, flagging piles of shit with the name of the person responsible. 1. METHOD : two Classic Models

CLASSIC CHC Approach: 6 months Hygiene sessions 20 sessions (each week) Learning through participatory activities reinforce good practice weekly meetings require homework : voluntary household improvements Members are

rewarded with social acknowledgement CLASSIC CLTS Approach One Triggering day + a few follow-up visits Village walk to shock community that they are eating their own faeces Community shamed into

building latrines and no open defecation Leaders enforce compliance with fines or social censure Faecal-Oral Transmission Route Most cost effective as it targets all routesFluids of diarrhoea transmission as well Fields Club Faeces Food

Mouth Community Health Approach 2. S CO Community Flies Led Total as all preventable sanitation

diseases: Social malaria, Fingers bilharzia, worms, skin Marketing PE disease, ARI, trachoma, HIV/AIDS Source: The F Diagramme: PHAST Step-by-step Guide 1998 Observed Indicators of Sanitation and Hygiene between

CLTS and CHC villages in Zimbabwe 100 90 80 70 60 50 40 30 20 10 0 % CHC 2011.Whaley & Webster

Comparing Health Promotion Strategies Type 1.PHAST Focus Narrow Disease Diarrhoea 2. Social Marketing Narrow 3. CLTS Narrow

4.CHC Approach Holistic Diarrhoea Diarrhoea Diarrhoea # Messages 17 % Change 5.6 % 4 1 17

13 % Country Uganda Burkina Faso 33% triggered Nigeria 47% Zimbabwe Skin disease Eye Disease Worms ARIs

HIV/AIDS Malaria / Bilharzia 1. Palmer (WSP-World Bank) (2005) 2.Cave & Curtis, 2002. 3. WaterAid , 2010. 4. Waterkeyn & Cairncross, 2005 Behaviour Change Imposed from outside Self directed Knowledge Behave Yourself Beliefs


THE HEALTH CHALLENGE : 11 million children die each year 2. SC OP E 88% can be prevented by good hygiene Where CLTS and CHC differ Classic CLTS is a NARROW focus on achieving sanitation CHC is a BROAD focus of all preventative diseases

sanitation is but one indicator out of at least 20 indicators of good hygiene in the home: Presentation by SNV for Banglasdesh Rokeya, 2009. Revitalised /evolved CLTS A working definition of 100% No open defecationsanitation or open/hanging latrine use. Effective hand-washing after defecation and before eating / taking or handling food. Food and water are covered. Good personal hygienic practices, such as brushing

teeth and trimming nails Latrines are well managed. Sandals are worn when defecating. Clean courtyards and roadsides. Garbage is disposed of in a fixed place, such as a pit. Safe water use for all domestic purposes. Water points are well managed. Waste water is disposed of down drains or in a fixed place. Objectives of the Programme : blanket coverage of all households with ZOD Higher CHC targets than ever before : 1. Community Led: Every house hold having a CHC member 2. Total Sanitation: all households having safe sanitation

Zero Open Defecation (ZOD) was adopted as the slogan. It means the same as ODF except it is easier to sing ZOD means: Open defecation free (no faeces on the ground) Latrine should not allow fecal transmission by flies to be properly covered toilet (Flies cannot enter) VIP with functional ventpipe (gauze to trap flies exit) 3. L EN GT

H Basic Assumptions of CHC : Positive peer pressure: Need to Achieve and Improve BC reinforced by community recognition and reward i.e. liberal and progressive THE BIG DIFFERENCE: OUR BASIC ASSUMPTIONS ETHICAL BEHAVIOUR CHANGE SHOULD: Enhance not undermine community

Use positive not negative peer pressure Build consensus rather than divide Appeal to group rather than individual : Recommendations Revitalise / Evolve CLTS CHCs should be started in areas where there is

already or where there will be CLTS CLTS Triggering is one of the 20 sessions in the THE END CLTS In Nigeria : extact from Revitalising CLTS: A Process guide, Wateraid . 2011 Unsatisfactory results: Reports from a monitoring exercise conducted by NTGS indicated a large number of unsatisfactory results and outputs from implementing the approach in Nigeria. Over 1500 communities were reported to have been triggered but less

than 500 to be open defecation Free the first step towards total sanitation. . The main reason suggested as poor facilitation. Regional training on CLTS by Unicef and WaterAid provided by Kamal Kar and Richard Chambers failed to result in significant progress in communities reaching ODF, leading to a demand for deeper analysis to At its mildest, this (CLTS) meant squads of teachers and youths, who patrolled the fields and blew whistles when they spotted people defecating. Schoolchildren whose families did not have toilets were humiliated in the classroom. Men followed women and vice versa all

day, denying people the opportunity even to urinate. These strategies are the norm, not the exception, and have also been deployed in Nepal and Bangladesh. 10. ETHICS Equally common, though, were more questionable tactics. Squads threw stones at people defecating. Women were photographed and their pictures displayed publicly. The local government institution, the gram panchayat, threatened to cut off households water and electricity supplies until their owners had signed contracts promising to build latrines. A handful of very poor people reported that a toilet had been

hastily constructed in their yards without their consent. 10. ETHICS A local official proudly testified to the extremes of the coercion. He had personally locked up houses when people were out defecating, forcing them to come to his office and sign a contract to build a toilet before he would give them the keys. Another time, he had collected a womans faeces and dumped them on her kitchen table. (Chaterjee, 2011). 10. ETHICS

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