Sunday, June 6, 2010

Health Promotion

Background to Health Promotion

While development in the Water and Sanitation Sector has been ongoing since the 1960’s, health promotion was first highlighted at Alma-Ata in 1978 with a call internationally for ‘Health for All by the Year 2000’. As safe drinking water was considered a primary prerequisite for good health, the 80’s was designated the Water Decade and strenuous efforts were made to provide safe drinking water for rural communities.

In an effort to improve conventional health ‘education’, which had been purely a top-down transfer of information from experts to recipients, the Ottawa Charter (WHO, 1986) revised the concept, which was now termed Health Promotion, defined in much broader terms as:

‘the process of enabling people to exert control over the determinants of health and thereby improve their health’

The Participatory Approach

The more people-centred ‘participatory approach’ in the 1990’s attempted to involve communities in their own development. The most well known varient of the participatory approach in the Water and Sanitation Sector is known as PHAST (Participatory Health and Sanitation Transformation) and was introduced into Sub Saharan Africa (Kenya, Uganda, Zimbabwe, Botswana and Ethiopia) as a regional pilot project in 1994. A number of projects were initiated and a “tool kit” of illustrations (100-200 drawings) were developed in each country for participatory activities such as ‘Nurse Tanaka’, 3 pile sorting, Story with a Gap, Blocking the Route, and un-serialised posters.
Constraints of Standard PHAST programmes

Whilst the activities in ‘Standard PHAST’ projects successfully empowered communities, (UNDP/WSP/IWSD, 1999) and increased health knowledge, the training tended to target the whole community loosely with no specific membership. Ad hoc meetings with the broad community meant that different people would attend different sessions so that there was no clear target audience. If no water and sanitation programmes followed the health promotion, expectations of assistance of the community were raised whilst nothing materialised. Lack of base line surveys, lack of identified indicators of hygiene behaviour change and ill defined target population meant that hygiene change was difficult to measure. Furthermore the process was time-consuming and with insufficient monitoring and support, extension staff did not always follow through or provide the necessary reinforcement to ensure implementation took place.

Although standard PHAST has theoretically seven steps, (Problem identification, Problem Analysis, Planning Solutions, Selecting options, Planning for new facilities and behaviour change, Planning for monitoring and evaluation, and Participatory evaluation) in actual fact there is more planning than action, and the ‘talking shops’ do not always translate into sustainable behaviour change in the home. Despite the planning, communities may not be sufficiently functional to operationalise these plans.

In 2005, an assessment of PHAST programmes in Uganda concluded that it was difficult to assess the difference between communities exposed to PHAST as against those where no health promotion programmes had taken place. Although with an estimated 4 million beneficiaries the cost of the programme (US$12 million) amounted to only 49c (US$) per beneficiary, the levels of hygiene behaviour change were marginal. PHAST areas had only a 9% higher latrine coverage after a 4 year programme and a basic hygiene habit such as covering drinking water appeared 2% higher in areas where no health promotion had taken place (World Bank-WSP, 2006). The 17 indicators that were presented showed an average difference between the intervention area and the control of 5.6% (with no p values published).
PHAST within Community Health Clubs

However the fact that Standard PHAST has largely failed to prove its cost-effectiveness to-date does not mean that the approach should be completely abandoned, as where it has been used in conjunction with Community Health Clubs there have been significant success in changing hygiene behaviour. The Consensus Approach uses the standard PHAST training but has been more successful in achieving behaviour change with most areas achieving total safe sanitation, and can demonstrate an average of 47% difference of over 15 indicators (p >0.0001). The community structure provided by a Community Health Club is the missing link, an effective mobilisation strategy that puts the final ‘T for Transformation’ in place.

Community Health Clubs ensures that participatory activities translate into action. Achievable hygiene changes are identified each week. Every session is backed up with homework for the week whilst group consensus and peer pressure encourages the compliance of members.

In addition, cost-effectiveness can be more easily measured in Community Health Clubs because:

* There is an identified membership

* There is a more structured programme of sessions

* There are pre-determined proxy indicators
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