Open access peer-reviewed chapter

# A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam and Zimbabwe to Control Diarrhoeal Disease

Written By

Juliet Waterkeyn, Victor K. Nyamandi and Nguyen Huy Nga

Submitted: February 14th, 2021 Reviewed: March 10th, 2021 Published: April 14th, 2021

DOI: 10.5772/intechopen.97142

From the Edited Volume

## Rural Health

Edited by Umar Bacha

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## Abstract

The Community Health Club (CHC) Model in Makoni District, Zimbabwe operated 265 CHCs with 11,600 members from 1999 to 2001 at a cost of US$0.63 per beneficiary per annum. A decade later, 48 CHCs were started in three districts in Vietnam with 2,929 members at a cost of US$1.30. Hygiene behaviour change was compared using a similar survey of observable proxy indicators in both projects, before and after intervention. In Vietnam there was a mean of 36% change in 16 observable proxy indicators (p > 0.001) which compared positively with Makoni where there was a mean of 23% hygiene change in 10 indicators (p > 0.001). In Vietnam, 8 Health Centers reported a reduction of 117 cases of diarrhoeal diseases in CHC communes, compared to only 24 in non-CHC communes in one year; in 8 Health Centers in Makoni, Zimbabwe, a reduction of 1,219 reported cases over a 2–9 year period was reported, demonstrating the efficacy of CHC both in African and Asian context. We suggest that regular government data of reported cases at clinics may be a more reliable method than self-reported diarrhoea by carers in clustered-Randomised Control Trials, which have surprised practitioners by finding negligible impact of WASH interventions on diarrhoea in rural communities.

### Keywords

• community health club
• hygiene behaviour change
• sanitation
• Vietnam
• Zimbabwe

## 1. Introduction

This study provides a comparison between the first Community Health Club (CHC) pilot project in Makoni District, Zimbabwe in 2000 [1, 2] to the first a pilot project of a ‘classic CHC’ intervention in Vietnam which was researched and presented in conference proceedings in 2010 but not published [3]. Our interest is to establish if these two interventions can be considered efficacious in the prevention of diarrhoea in Community Health Club households in two very different settings.

### 1.1 Replication of the community health club approach

In the past 20 years, over 3,000 Community Health Clubs have been started in 12 countries in Africa reaching over 2.5 million people [4] but in SE Asia, only in Vietnam. Although CHCs have been replicated at a small scale in many countries, only in Zimbabwe and Rwanda have they gone to scale throughout the country [5]. In Zimbabwe most Non Governmental Organisations (NGOs) now use CHC as a standard means of mobilising community in Water and Sanitation Programmes and this method has been endorsed in both the Water Policy and the Sanitation Policy for the country and Ministry of Health is the custodian of this initiative though the Environmental Health Department. In Rwanda the government has taken a lead in coordination of all NGOs into a single National Community Based Environmental Health Promotion Programme (CBEHPP) in which CHCs have been started in all villages throughout the country [6]. A recent systematic review of studies reporting the effect of Community Health Clubs on behaviour relating to drinking water usage, sanitation, hand washing and clean kitchen hygiene [7] demonstrated a strong pattern of community response and a significant change in a wide raft of safe hygiene in virtually all such programmes conducting the ‘Classic CHC’ training as originally conceived [1]. However, this study is the first to compare CHC in Africa to a similar CHC pilot project in South East Asia.

### 1.2 Community health clubs in Zimbabwe

Makoni District in Zimbabwe was the first site internationally to field test the concept of a Community Health Club in 1994, and by 1999 an organisation called Zimbabwe AHEAD had been started to replicate and scale up the approach throughout the country.

Community Health Clubs are defined as a voluntary group of men and women, of all ages, education and income level, who are dedicated to improving the health and hygiene facilities and practices of all members so as to alleviate all preventable diseases and manage public health within the given catchment of the club. CHC are usually supported technically by Environmental Health Technicians (EHTs) responsible for public health who are usually based at Rural Health Centers who supervise voluntary community facilitators in at least 20 health promotion sessions every week for at least six months. The process of training has been well documented in the training manual [8].

### 1.3 Replication in Vietnam

In 2009, The Ministry of Health in Vietnam was looking for a hygiene behaviour strategy to galvanise communities into changing their high risk behaviour, as several approaches including PHAST [9], Community Led Total Sanitation (CLTS) [10] and Social Marketing [11] had already been tried in some areas but had not succeeded in reaching the last percentile. There was at this time much debate as to the most cost-effective methodology to achieve permanent hygiene and sanitation behaviour change.

As CHCs had not been used in S.E Asia at that time, there was some concern that with higher living standards in Vietnam, the CHC Approach could be too basic for rural Vietnamese. However, the level of literacy in women at 92% and in men at 96.1%, in Vietnam [12] was not much higher than in Zimbabwe which was 87.2% literacy for women and 94.2% for men in 2010 [13]. At the time, the national average for rural water supply household coverage in Vietnam was 83% whilst rural household sanitation was only 55%, of which only 18% of latrines in rural areas met government standards of hygiene [12, 14]. Again, this compares to Zimbabwe where rural sanitation was estimated at 25% and rural water supply at 79%. Whilst the two cultures of Zimbabwe and Vietnam appear quite different, the demographic level are not dissimilar (Table 1).

ZimbabweVietnam
National water supply household coverage79%83%
National rural sanitation coverage24%55%
Literacy in women / men (2010)87.2% / 94.2%92% / 96.1%
Number of Provinces13
Number of Districts13
Size of intervention area in hectares802,800225,100
Population in whole district (2003)358,733444,488
Households in whole district65,22598,775
% Households with CHC in whole district17%3%
Number of intervention wards /all21/357/70
Number of CHC26548
Number CHC members11,4502,939
Number of beneficiaries63,70013,258
Average no members /CHC4368
Households in intervention ward/commune38,18110,824
Estimated % CHC coverage of households in intervention wards30%21% and 36%
Average Size of household5.64.5
Period of intervention (1–2 years)1999–20002009–2010
Number of health sessions held (I year)3,731960
Number of latrines built in 2 years2,400441
Cost per beneficiary per yearUS$0.63US$1.30

### Table 1.

Demographic comparison between CHC intervention in Zimbabwe and Vietnam showing scope of project.

## 2. The interventions

### 2.1 Makoni District, Zimbabwe

By the year 2000 there were 265 CHCs in 21 out of 35 wards of the district with 11,600 CHC members, involving an estimated 63,700 beneficiaries, calculated by the average of 5.6 family benefitting from improved hygiene in each family. During the period under review there had been 3,731 health promotion sessions held by 14 EHTs. Subsidies for VIP latrine construction at that time resulted in 2,400 VIP latrines being constructed in 2 years, which was considered remarkable given the total for the country was only 8,000 in 1998. No water component was included in the project, but the district was higher than the national average with 676 functional boreholes and 839 family wells [12]. The project was completed in 2000 when most donors withdrew from Zimbabwe for political reasons, and the CHC were largely left to their own resources, except those which continued with income generating activities started in a later programme [2].

### 2.2 Adaptation of the CHC approach in Vietnam

The pilot CHC project was started in three Provinces of Northern Vietnam, Son La, Phu Tho and Ha Tinh with 48 CHCs with 2,393 members. An active health club of committed members was established in every village to manage environmental health and encourage community hygiene through non risk practices. Village Health Workers already part-employed with Ministry of Health were trained to conduct the sessions. The period of intervention was similar in both countries being from 18 months to 2 years with 20–24 sessions completed in a six-month period of weekly training.

### 2.3 Comparative scope and spread of the two interventions

The scope of the programme in Zimbabwe was five times larger than the pilot project in Vietnam. However, although the size of each CHC appearslarger in Vietnam with a mean of 68 members compared to the Zimbabwean CHC with 43 members, those in Vietnam counted allmembers at registration but with no indication if they attended or not, as membership cards were not used. In Zimbabwe, only the activemembers who completed training were counted as members; if all registered members were counted the mean would be around 80 members. Also, the CHC density (spread) is high in Makoni with 21 out of 35 wards in the district with CHC, whereas in Vietnam only in 7 out of 70 communes had CHC. In Vietnam the two communes had a spread of 21% CHC households in Son La and 36% in Ha Tinh, whilst that of Phu Tho was not calculated. The mean coverage in Makoni was 30% but this ranged from 9% coverage in a new area such as Chiduku, to 113% in Nyamidzi where all households were in a CHC, some with more than one per households as a CHC Members. Table 2 above shows the % spread in the 8 wards where data was collected from local Health Centers.

WardsStart Year of CHCSpread of CHCAll h/holdsCHC members
Ruombwe199580%2,2241,777
Nyamidzi1996113%*13581540
Tikwiri199868%753516
Mutanda199843%1186513
Dumbamwe199878%939730
Sangano199820%1558309
Inyati Mine20009%2900253
Chiduku2000NANANA

### Table 2.

Spread of CHC in wards where health centers have provided reported cases of diarrhoea.

Over 100% indicates more than one CHC member per household in the CHC.

## 3. Methods

### 3.1 Objectives

This study seeks to compare outcomes from the Vietnamese pilot project and compare it to the Makoni CHC pilot project, in five measures: improved knowledge, hygiene and sanitation behaviour change, reduction in disease, cost-effectiveness and stakeholder perceptions.

### 3.2 Data collection

#### 3.2.1. Data Collection in Zimbabwe

A case/control study was conducted in Zimbabwe in three districts, of which one of the districts was Makoni. The standard indicators used to measure hygiene and sanitation behaviour change included a spot observation of 17 indicators taken in 25 randomly selected CHCs, and within each CHC a random sample of 382 CHC members. These indicators were observed before and after in the CHC intervention villages and in the 113 households of non CHC members, in control villages using similar empirically observable proxy indicators to quantify changes in hygiene facilities and standards of cleanliness. There was no self-reported behaviour. Full details of data collection and analysis are fully described elsewhere [1, 2].

#### 3.2.2.1 Quantitative

• A household survey was carried out twice (pre and post) in each of the three Districts. As every household was surveyed in every village, there was strong statistical validity. Each enumerator was meant to survey 100 respondents, but when there were not enough CHC households, they also surveyed non-CHC households and the respondents were not differentiated in the data. Therefore, these statistics may show a combined level of CHC and non CHC, and the rate of change within the CHC membership may therefore be higher than shown [3].

• Secondary data was collected from 8 clinics in CHC areas and 5 clinics in non-CHC areas by the Ministry of Health and provided for analysis. The number of reported cases for Diarrhoea, Dysentery and Food Poisoning (DD & FP) in 2009 was collected and compared to those in 2010.

#### 3.2.2.2 Qualitative data

• Structured interviews were done with key informants which included district officials and nurses from Ministry of Health and village leaders [3].

• A spot observation of a sample of six CHCs in action was done and six individual homes were visited, one in each of the Community Health Clubs.

### 3.3 Analysis of data

In Vietnam, analysis of data from each Province of the base line and post line survey was done by Ministry of Health officials and provided to one of the authors in excel for her interpretation. All data was cleaned and in this process it was decided to discard data from two of the districts (Phu Tho and Son La) because the standard household survey had been adapted by each district, which made comparative analysis difficult. Therefore, only data from Ha Tinh is used because it could provide raw data for the full base line and post intervention survey that could be checked. In this district a survey of 7,187 base line respondents, and 1,200 post intervention respondents was undertaken, and used to ascertain levels of knowledge and behaviour change. It was converted into SPSS statistics package and standards test of Chi square used to compare data sets [15].

### 3.4 Sources of bias and confounding

Some interviewer bias can be expected, as the data from the household survey in both Zimbabwe and Vietnam was collected by the same Village Health Workers who facilitated the project. However this was triangulated in spot checks using observable indicators which could be verified empirically.

The statistics collected from the Health Centers both in Zimbabwe and Vietnam are considered impartial as reported cases were not influenced by the objective of this research. The data was collected and analysed by each district by Ministry of Health and presented in their annual reports. National statistics also show a gradual trend in improvement of most communities in Vietnam over the previous five years (NTP2) [12]. Therefore, to identify the impact of only the CHC training we compared CHC with non CHCs areas as a control for clinical reported cases.

Ministry of Health statistics in Health Centers were taken to track the pattern of disease in wards or communes where CHCs were operational in both countries despite the fact that these figures may not reflect the true burden of disease, as only the most critical cases will be reported. This is not critical to this research as it is the pattern not the extent we are interested in examining. In Zimbabwe, the two wards where there were large hospitals were not used because the catchment of patients was referred from other areas and therefore could not be attributed to the CHC training.

In Vietnam, the CHC Pilot project was not the only health promotion being done in these districts during this one year period. In Ha Tinh, a Unilever Programme using extensive Social Marketing techniques promoting handwashing with soap was running concurrently for one year in all communes, including the CHC communes. Therefore, to avoid confounding and to measure the impact of onlythe CHC, we have only sited findings from topics which were not included in Unilever Information Education and Communication (IEC) material.

## 4. Results

### 4.1 Vietnam

The results for Vietnam are provided in five measures: improved knowledge, hygiene and sanitation behaviour change, reduction in disease, cost-effectiveness and stakeholder perceptions.

#### 4.1.1 Improved knowledge

The spot observation done in two CHC per Province provided ample anecdotal evidence of the popularity of the CHCs, with high levels of attendance with an average of 68 people at each session.

The Vietnamese showed a strong interest in health education and although basic knowledge of hygiene was high, it did not seem that the training was pitched too low for their level of education. Two questions were asked to establish difference in health knowledge: the causes and prevention of diarrhoea and how to make Sugar Salt Solution (SSS) a homemade recipe to treat dehydration. Whilst the former was well-known due to Unilever programmes and showed little difference before and after the training (94%), knowledge of how to make SSS, was increased by 42% (Figure 1) and is more reliable an indicator as this was not taught in the Unilever programme.

#### 4.1.2.1 Hygiene in the home

Of the three provinces we chose to use Ha Tinh with 12 CHC and almost 900 CHC members as it provided the most reliable information on levels of hygiene behaviour change as summarised in Figure 2 below. Across 17 indicators, only one indicator, the use of bednets, i.e. ‘protection from mosquito’ showed no significance at all, as it was 100% in both pre and post intervention survey. In the other 16 indicators, all practices showed compositive behaviour change of 36% (the mean of all 16 indicators) after one year: ‘safe water source’ and ‘drinking water treated’, which had been advocated by previous WASH projects were significant at p > 0.05; the other 14 indicators, not used in previous projects, were highly significant (p > 0.001).

• Hand washing facilities improved by 45% (from 14–59%)

• use of soap improved by 53% (from 6–63%)

• Safe storage of water increased by 54% (from 35–89%)

• 89% households had a combined measure of safe drinking safe (source, storage and treatment)

• The coverage of toilet increased from 35–56% after a year, with 265 new pit latrines, 7 covered pit latrines, 71 new composting latrines, and 71 with a septic tank (414 in total).

• Safe storage of kitchen utensils improved by 23% (from 68–85%)

• ‘Well organized kitchens’ (plates and food stored safely) improved 55% (from 21–76%).

• Clean swept floors increased by 57% (from 38–95%)

• Cleanliness of bedding improved by 14% (from 83–97%)

• Clean compound surrounded the house improved by 33% (litter decreasing from 36–3%)

• fly control increased by 30%, with 60% of people owning and using a fly swot to kill flies

• homes practicing some form of vermin control increased by 42%, from 23–61%

#### 4.1.2.2 Speed of sanitation behaviour change

Community Health Club records were used to analyse the speed of adoption by the CHC members. At base line there was 99% open defecation in Ha Tinh (Figure 3). When a survey was taken only one month into the training when CHC members had attended 1–4 sessions, open defecation had decreased to 84%, with 13% now practicing cat sanitation and 3% having constructed a permanent latrine.

By the second and third month when between 5 and 12 sessions had been attended, open defecation had plummeted to only 2% with a massive uptake of 87% practicing cat sanitation, with 10% constructing permanent latrines and 1% having a temporary latrine.

By the time more than 20 sessions had been done, it was found that 49% had constructed a permanent latrine and 50% were still using cat sanitation with 1% having a temporary latrine.

Thus in 5 months Zero Open Defecation (ZOD) had been achieved.

#### 4.1.3 Reported cases of diarrhoea, dystentry and food poisoning

Diarrhoea, Dysentery and Food Poisoning (DD & FP) are listed together as one category in reported cases in Health Centers in Vietnam. The communes selected for CHC were in most cases, the more challenging areas as shown by higher DD & FP at baseline (Figure 3, above). The data from all three provinces showed the same pattern of reduction in areas where Community Health Clubs were fully operational, all with a downward trend in reported cases. In total there were an estimated 459 saved cases in CHC Communes.

The Community Health Club communes showed a sharp decline in reported cases of DD & FP from a total of 171 cases to 17 cases in one year, saving an estimated 154 cases, a mean reduction of 61 cases in each commune from 2010 to 2011. By contrast, control communes with no CHC, reduced in DD & FP reported cases from 99 to 75, only 24 down from the previous year (Figure 4).

Of the non-CHC Control communes, only Pi Toong in Son La decreased in DD &FP, whilst in the two other non-CHC Communes Thach Vinh and Thach Dai reported cases of DD & FP increasedin reported cases, despite the fact that in the latter a Social Marketing campaign was being conducted. In Son La Province, with a higher density of 12 CHC in 55 villages in the catchment of the Health Centre, there were no other public health programmes, therefore we attribute the decrease in DD & FP to the CHC intervention.

However, the data could not determine if there were fewer reported cases at Health Centres due to successful prevention of DD & FP by safe hygiene, or due treatment at home using SSS, but either way these numbers show some positive effect. Nurses interviewed from the Health Centres attributed the decrease in cases to the CHC training and maintain that patients were more able to distinguish between when it is necessary to come to the clinic for treatment and when they can treat dehydration at home. This clear pattern in six well matched communes, provides some indication of the potential of hygiene and sanitation training in CHC to affect health outcomes.

### 5.9 The methodological debate

We are receiving mixed messages in recent literature on the effectiveness of WASH to reduce diarrhoea and the jury is still out as to exactly which methodology is able to change people’s habits in the long term to ensure non risk hygiene and sanitation behaviour. Whilst the Burden of Disease attributable to WASH has apparently been reduced from 4.2% to 1.5% in the last 30 years [3], some recent trials has led to experienced practitioners in the public health sector to question whether WASH interventions are in fact impacting on diarrhoea [30]. Our limited research indicates that comprehensive WASH programmes such as was done in Zimbabwe and Vietnam does lead to reduction in diarrhoal disease.

## 6. Conclusion

Whilst epidemiologists and trialists struggle with high end statistical data, to inform the Environmental Health Departments of Ministries of Health on the efficacy of community interventions designed to prevent diarrhoea, the curativewing of Ministry of Health continues to rely simply and systematically on the number of reported cases at Health Centres to indicate trends in the burden of disease. These trends over time may be more reliable than snapshot interventions of clustered-randomised control trials which seldom have enough time to understand the dynamics of community response. Whilst the routine data we present here has obvious limitations in that it may fail to represent the fulldisease burden, with the crisis of reliability in the WASH literature in the past few years, we may find that watching the pattern of reported cases in the catchment area of an intervention over time may be the nearest we can get to assessing impact on health by such interventions as a Community Health Club programme.

## Acknowledgments

In Vietnam, the main author was funded as a consultant by DANIDA 2009-2010 in collaboration with the Ministry of Health and acknowledges the input of local consultants and officials.

In Zimbabwe, the pilot project in Makoni District from 1999 to 2001 was funded by DANIDA in collaboration with the Ministry of Health, and we acknowledge the efforts of Environmental Health Department which was the main implementor of this programme.

Thanks also to Zimbabwe AHEAD (now Africa AHEAD) for quality of training and support to Makoni District.

## Conflict of interest

The corresponding authors is the original architect of the CHC Methodology and therefore has obvious bias.

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Written By

Juliet Waterkeyn, Victor K. Nyamandi and Nguyen Huy Nga

Submitted: February 14th, 2021 Reviewed: March 10th, 2021 Published: April 14th, 2021