Impact Evaluation of Community-Based Health Programs in Rwanda
Condition: Diarrhea; Malaria
MeSH terms: Diarrhea
Study type: Interventional

Summary: 
      Community Health Clubs to improve local sanitation, hygiene and health conditions have been
      implemented in several countries in Africa and Asia with some success. The Ministry of Health
      in Rwanda has committed to rolling out a program designed along similar lines, the Community
      Based Environmental Health Promotion Program (CBEHPP), in all 15000 villages across Rwanda.
      The main objective of the program is to achieve 'zero open defecation' in all villages of
      Rwanda, at least 80% hygienic latrine coverage and improvements in a range of health
      behaviors such as the use of mosquito nets, hand-washing with soap and the use of household
      water treatment.

      To evaluate the impact of the program on health, other socio-economic outcomes and community
      functioning, a single district has been chosen where 150 communities will be randomized to
      receive the intervention immediately or 18 months later. The evaluation is led by US based
      Innovation for Poverty Action (IPA) through researchers based at the National University of
      Rwanda, Georgetown University, London School of Hygiene and Tropical Medicine and New York
      University. The research team will work in close collaboration with the implementing team,
      which consists of the Ministry of Health, Rwanda and Africa AHEAD.

      The study will span three years, beginning in May 2013, and ending in late 2015.
    

Detailed description: 
      Preventable diseases such as respiratory infections, diarrheal diseases and malaria account
      for a large share of mortality in low income economies. For example, diarrheal diseases kill
      nearly 2.5 million people worldwide and account for a considerable share of under five
      mortality in low income countries. Broad-based economic development that includes
      improvements in infrastructure and service delivery can address the challenges associated
      with the infectious disease burden. But for many countries, these improvements are far in the
      future and/or very costly. Behavior change of individuals can also address these challenges
      and more importantly can be done now and relatively cheaply. Understanding how to produce
      this behavior change in needy contexts is crucial to the short and medium term response to
      the high costs imposed by these diseases. This protocol outlines an evaluation of an
      intervention aimed at producing sustainable behavior change around health, hygiene and
      sanitation. The evaluation consists of two parts: firstly to evaluate the health and
      socio-economic effects of a well-designed and supported community health club intervention.
      Secondly to examine whether the intervention can deliver health and other benefits utilizing
      the resource base available in this context. The answer to this latter question informs the
      scalability of the intervention. The overall objective of the study is to evaluate whether
      and how community hygiene/health clubs are an effective and sustainable response to
      addressing broad health, sanitation and hygiene needs in low-income countries.

      A particular challenge associated with health interventions, is the extent to which
      free-rider problems mediate the adoption of improved behaviors. The community health club
      approach with regular meetings, is well placed to address these collective action challenges.
      Community health clubs provide a vehicle to inform and incentivize households to change their
      behavior in relation to a range of health outcomes. The information component arises from the
      six month long weekly courses covering a wide range of health, hygiene and sanitary subjects
      and facilitated by a community health worker. The incentives for sustainable behavior change
      follow from the social sanctions and rewards that club members can impose/bestow on members
      accordingly. As with other behavior change programs that have incorporated information
      components that emphasize the benefits of better health behavior, the evidence base for what
      works in this domain remains thin. The community health club approach is appealing largely
      because it mobilizes local resources and is plausibly cheaper and more sustainable than other
      top-down interventions.

      To evaluate the impact of the program on health, other socio-economic conditions and
      community functioning, a single district has been chosen where communities will be randomly
      assigned to receive the intervention immediately or 18 months later. The evaluation is led by
      US-based Innovation for Poverty Action (IPA) through researchers based at the National
      University of Rwanda, Georgetown University, London School of Hygiene and Tropical Medicine
      and New York University. The research team will work in close collaboration with the
      implementing team, which consists of the Ministry of Health, Rwanda and Africa AHEAD.

      The evaluation will measure impact heterogeneity with respect to key inputs that predict
      success of CHCs, including training and competence of CHWs, the quality of training
      materials, and community functioning. The evaluation will also document in detail the cost
      structure of the low- and high-resource versions of CHCs in order to inform the MOH about the
      most effective strategies for successful scale up of CHCs nationwide. More broadly, other
      governments, donor organizations and foundations will benefit from rigorous evidence on the
      effectiveness and cost-effectiveness of using health clubs to address health and sanitation
      challenges.
    

Intervention name(s): Classic Intervention; Minimum Intervention
Intervention type(s): Behavioral; Behavioral
Intervention description(s): The standard "classic" approach will implement a total of 20 community health club sessions delivered through weekly education programs in the target communities as per the training manual. Community health workers (CHW) will receive careful training in the delivery of the CBEHPP instruction. High quality instructional materials (in color) will be used. Club members will each receive a membership card to be used to track attendance and compliance. Finally model home competitions and a graduation ceremony will be held. Monitoring of the clubs will be conducted by community health workers using mobile phones.; The "lite" trial arm will only implement 8 sessions covering all the WASH topics. It will be facilitated by CHWs receiving minimal training and using black/white photocopies of instructional materials. Members will not be issued with membership cards and will not have a graduation ceremony or home garden competitions. Minimal monitoring of this arm will be carried out by environmental health officers.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: weight-for age; height-for-age; water sanitation facilities; hygiene behavior