Unit 3.3

Social and Behavioural Health
MODULE - 3
Theoretical and
Conceptual Issues in
Health Promotion and
Health Education
MODULE
Theoritical and Conceptual Issues in Health

Promotion and Health Education
Module Description
Module describes the ecological approach nature of health promotion in providing

understanding of health and disease. Public health focuses on population health and
therefore has the challenge of understanding human behavior in diverse
circumstances. This module will extensively treat behavior theories that facilitate the
understanding of behaviors relevant to various health consequences at the
individual, group, community and organisational-levels. In public health, behavior
change is produced through health programming and research, and will feature in
this module as a practical guide or tool for system and individual intervention for
considering theoretical and conceptual issues related to health behavior and relevant
antecedents that predispose to behavior.
Unit 3.1
Health Promotion and Health Education
Unit 3.2
Behaviour Theories
Unit 3.3
Health Program Planning, Implementation and Evaluation
Unit Table of Contents

Unit 3.3 Health Program Planning, Implementation and Evaluation
Topics Page No.
Introduction
3.3.1 Immunisation program
3.3.2 Sanitation
3.3.3 Health-Risk Reduction and Safety Practices
3.3.4 Breast Self-Examination
3.3.5 Conclusion
Summary
Activity
Reference
Multiple Choice Question
Multiple Choice Question Answer Key
Learning Objectives:
• Describe how one would plan and choose appropriate communication

strategies to promote immunisation activities and remove barriers to
accessing the service.
• Describe the possible barriers that might prevent improvements on sanitation
• Describe Health-risk reduction and safety practices
• Describe Breast self-examination to prevent breast cancer
Learning Outcome:
• Understand appropriate communication strategies to promote immunisation

activities and remove barriers to accessing the service.
• Understand the possible barriers that might prevent improvements sanitation
• Identify the Health-risk reduction and safety practices
• Understand Breast self-examination to prevent breast cancer
Social and Behavioural Health | Theoretical and Conceptual Issues in Health Promotion and Health
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There is no doubt of the efficacy of immunisations in preventing infectious diseases

or of the value of good occupational health and safety programmes in reducing the
frequency and severity of work-related diseases and injuries. There is general
agreement that early detection and appropriate treatment of incipient diseases will
reduce mortality and lower the frequency and extent of residual disability from many
diseases. There is growing evidence that elimination or control of risk factors will
prevent or, at least, substantially delay the onset of life-threatening diseases such as
stroke, coronary artery disease and cancer. Health promotion and Education for
effective campaign for immunisation program, sanitation, health-risk reduction and
safety practices, and breast self-examination is described.
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3.3.1 Immunisation
Advocacy and communication form one of the five key EPI operations.
Advocacy refers to ways of delivering an argument effectively, so that you gain the
support and commitment of policymakers, community members and other
stakeholders, and are able to ‘put the case’ successfully for increasing immunisation
coverage. Communication is the transmission of information from one person to
another, or from a source to a destination.
Fig 3.3.1: Key EPI Operations
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Immunisation programmes may be unsuccessful if incorrect or inadequate

information is transmitted to the community. Sometimes, even though correct
information may be communicated, it may be ineffective in achieving the desired
outcome. It is important that you, as a Health Extension Practitioner, use terms that
are readily understood when you talk to members of the community, ensuring that
you appreciate local problems and show respect for local customs and culture. One
way to improve communication with members of your community would be to
organise a committee to look into reasons why people do not come to be vaccinated,
or do not complete their vaccinations. This would help to,
• Improve relations between you as a Health Extension Practitioner and the

community
• Promote participatory decision-making to improve community involvement
in the EPI
• Support the community to develop strategies for identifying and tracing
immunization defaulters
• Improve the quality of the immunization service
• Encourage the community to identify and report outbreaks of communicable
diseases
• What do you hope this would achieve in the long term?
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3.3.1.1 Planning a Communication Activity
A communication strategy should be included in your annual EPI action plans.

There are likely to be many possible barriers to effective communication between
Health Extension Practitioners like you, carers, the community and stakeholders. It is
important that you identify these barriers and do your best to eliminate them. The
aim is that your messages will be understood and will result in changes in
behaviour, which will increase EPI coverage rates and decrease dropout rates.
Fig 3.3.2: Planning process for Effective Communication
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3.3.1.2 Strategies and Activities
There are a number of possible strategies or activities you can use to get your
message across to the community. These might include a community conversation or
a community mobilisation or advocacy programme.
Behaviour Change Communication (BCC) is a process of developing communication

strategies to promote a positive change in health-related behaviours in a community,
appropriate to local circumstances. This can only be done by sustained work with
individuals and communities to explain the issues and implications involved and
support people as they try to understand them.
3.3.1.3 Common methods of BCC in Immunisation
When you want to communicate a message, for example about the advantages of
having your child immunised, you should first identify or decide who the message is
intended to influence. The message to be sent to a group of school teachers, a
women’s group, a youth group, or a group of religious leaders is not the same, even
though the aims of all these messages might be to increase immunisation coverage.
Their level of understanding of the issues involved is likely to be quite different.
Therefore in preparing a BCC message, the first step should be to decide who you
intend to address. This is your target audience.
Suppose the message you want to communicate is that there are many diseases that
are serious and may lead to death, but they can be prevented by immunisation;
therefore, bringing babies and children for immunisation from an early age is
beneficial. Who would your target audience be? (Who would you want to
communicate this message to?)
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3.3.1.4 Advocacy
Advocacy is a process or activity that aims to influences politicians, policy-makers

and opinion leaders. In the context of EPI activities, this could refer to an activity
that aims to gain the support of stakeholders, community leaders and local
politicians, and to encourage community acceptance of and commitment to the EPI.
3.3.1.5 Community Mobilisation
Community mobilisation is a process of gaining the involvement of everyone in the

community for an action towards a particular goal.
In the EPI, mobilising the community is likely to enhance the programme and hence
make it much more effective. In order to mobilise the community you will need to
interact with your target audience members in person. You should prepare your
message in a clear and simple way. You can have the interaction in community
meetings, in religious places, market places, etc. Public meeting for large community
may be appropriate.
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3.3.1.6 Community Conversation
One of the ways in which it is possible to influence behaviour is through

a community conversation. This is a collective discussion of a particular issue, such
as the causes of high dropout rate in the immunisation programme, and can lead to a
way of finding solutions to particular problems.
Fig 3.3.3: Community Conversation
Such a conversation will be successful when everyone is given the opportunity to be
heard. Many will not participate fully in a meeting unless they feel at ease and
believe their opinions will be heard.
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3.3.1.7 Factors to be considered for successful Community Conversations
The factors include,
• Decide on the purpose of the conversation and advertise it widely.

• Decide who should attend or be invited.
• Prepare an agenda for the meeting.
• Decide on the date and time; make sure that everyone you want to attend is
informed about when and where the meeting will take place.
• Choose a meeting place where there is little interference, so that everyone will
be able to hear one another’s views.
• Facilitate the conversation in an open and non-judgemental way, so everyone
feels included and respected.
3.3.1.8 Interpersonal Communication
Interpersonal communication is a term for face-to-face interaction with an

individual, or a small group of people, for the exchange of information because it is a
face-to-face interaction, the people involved have eye contact, they hear each other,
and they can respond to each other’s ideas. Note that interpersonal communication
is a two-way process, where everyone learns from each other — including you!
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3.3.1.9 Interpersonal Communication Skills
The important interpersonal communication skills include the following steps,

• Welcome the client warmly and offer a seat.
• Empathise with the client.
• Speak in simple terms, using easy language; give examples that the caregiver
is likely to understand.
• Motivate by praising the caregiver for bringing the child for immunisation
and encouraging them to return for the next dose.
• Listen actively; active listening is very different from just hearing. It is
listening to another person during a conversation in a way that shows your
understanding and interest. It encourages the other person to be more
involved in the conversation.
Fig 3.3.4: Active Listening
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3.3.1.10 Asking Questions Sensitively
It is important to give your client a chance to ask questions. This will help you to see
how much she has understood and accepted what you have discussed. You can also
ask her questions that enable you to assess her attitudes and the likelihood of
positive behaviour change but questioning must be done sensitively!
What questions might you ask a mother in one-to-one interpersonal communication

if you think she may drop out of the immunisation programme?
Asking about a caregiver’s worries about immunisation is an example of an open

question, i.e. a question that encourages the client to answer in her own way and
share her concerns with you. You should avoid asking closed questions where the
caregiver can simply answer ‘Yes’ or ‘No’. A closed question does not allow you to
check whether the client has really understood the question, or really knows the
answer.
Here is an example of a closed question: ‘Did your child complete all her immunisations?’
Change this into an open question on the same topic.
When asking questions, always give time for the client to think and answer. Let the
client answer freely and do not interrupt while the client is answering.
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3.3.1.11 Meeting with target audiences to promote EPI activities
In your efforts to increase immunisation coverage and decrease dropout rates, you
are likely to come across various interested groups of people and organisations.
These may include health staff at various levels, politicians and policy-makers,
community leaders, representatives from the private sector and from the NGOs
(non-governmental organisations, such as UNICEF, AMREF and others), parents,
and journalists. You may also particularly want to meet people from those parts of
the population that have not yet been reached by the immunization programme.
3.3.1.12 Meeting with Community Leaders
Community leaders may include kebele leaders, clan leaders, religious leaders, elders
and school leaders, and the leaders of women’s and youth groups. You should try to
gather information about the community you are working in before you meet such
community leaders. To increase the effectiveness of your meeting, you should
identify who the relevant participants will be, decide on an agenda and what issues
to discuss, and make sure that all those you want to attend the meeting are aware of
the agenda, and where and when to meet.
3.3.1.13 Meeting with Parents
One of the most effective ways to get a range of opinions in a short space of time
might be to arrange small focus groups, with clear guidelines from you about the
topic that the discussion should ‘focus’ on. The ideal number of participants in a
focus group is between six and ten, with a facilitator who keeps the discussion
focused on the agreed topic (in this case, immunisation) and makes sure that
everyone’s views are heard. You could select particular participants, such as parents
you think may be unlikely to bring their children for immunisation.
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3.3.1.14 Meeting with NGOs and other partners
Try to meet with any other partners or institutions who you think might be able to
help improve the immunization service. Who these might be will depend on your
community, but could include traditional birth attendants (TBAs), traditional
healers, private health practitioners, volunteer groups and representatives of NGOs
that focus on health — particularly the health of children.
3.3.1.15 Meetings with special groups
In your community you may be aware of some special groups who have been
largely unreached by immunisation services, or have chosen not to participate in
them. You should try to include such people or groups in your meetings and
planning process right from the start. Some examples of special groups include,
• Pastoralist groups
• Migrant workers
• Ethnic or other minority groups
• Groups in geographically remote areas, who may find it difficult to reach the
site of the immunisation services
• People who are injured, sick or disabled, who may find it difficult to get to
where immunisations are taking place
• Religious or traditional sects that refuse immunisation
• Refugees
• Homeless families
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3.3.1.16 Negative rumours about Immunisation
Rumours about bad consequences of immunisation often circulate in communities. If

such negative rumours are not dealt with appropriately, they can cause serious
problems for the effective delivery of immunisation services.
Any negative rumours about immunisation that you hear are circulating should be
communicated to your supervisor as soon as possible. The following suggested
actions cannot be carried out by you alone, as the local Health Extension Practitioner;
you will need the full involvement of health centre officials and the district Health
Office. Immediate reporting is important and advice should be sought before you
take action.
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3.3.2 Sanitation
Promotion of practices that can prevent transmission of the pathogens that cause
diarrheal diseases is therefore hugely important. These practices include
handwashing with soap, proper handling of food and water purification. Where
adequate sanitation is available coupled with improved hygiene behaviours, there
can be dramatic reductions in the incidence of diarrhoea. Improvements can also be
expected in other areas such as a cleaner environment, safer water and food, better
nutrition and hence improved learning among school children and improved dignity
and privacy for everybody, especially women.
The behaviour change strategy would also need to identify potential target audiences
for the campaign. If there are inadequate resources to address every target audience
at the same time, then some will need to be prioritised. For example, you might give
priority to audience groups that comprise the largest proportion of the target
population, or are identified as having high public health importance, or likely to be
most receptive to communication messages.
Fig 3.3.5: Supplying water in closed containers with secure lids
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3.3.2.1 Behavioural barriers to improving Hygiene and Sanitation
The behavioural barriers may be the result of personal or socio-cultural factors, or

may be due to service and infrastructure issues, or to economic or environmental
factors.
3.3.2.2 Personal barriers
Personal barriers include those resulting from lack of knowledge or awareness.

People may not have the habit of regular bathing, or good handwashing behaviour
because of a lack of time in busy households. It may also be that there is no scoop
available in the household for moving faeces, or no jerrycan in the home to use for
storing water.
3.3.2.3 Socio-cultural barriers
There are a number of social and cultural or religious barriers which might prevent
people from adopting good WASH behaviours. For example, many mothers believe
that child faeces are harmless and hence they do not discard them properly.
Fig 3.2.6: A women cleaning latrine
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3.3.2.4 Economic barriers
A number of economic barriers exist for urban communities and these include the
high costs of obtaining a household pipe connection and acquiring a latrine facility,
the cost of water, and the cost of soap.
3.3.2.5 Environmental barriers
There are often environmental constraints to provision of adequate latrine facilities.

For example, hard rocks increase the cost of constructing latrines because it makes it
difficult to dig a pit. Sandy soils or marshy environments are not suitable for
construction of latrines.
3.3.2.6 Interventions to promote improved Hygiene and Sanitation
A health promotion intervention would use these approaches for different purposes.
Here are some examples of the aims they might be used to achieve,
Social change communication aims to increase community involvement in selecting

appropriate design options for water and sanitation facilities, to change cultural
beliefs and to promote Community-Led Total Sanitation (CLTS). You will learn more
about CLTS.
3.3.2.7 Community-Led Total Sanitation (CLTS)
It is a method for mobilising communities to completely eliminate open defecation by

triggering collective behaviour change. In Ethiopia the name has been modified and
you are more likely to come across ‘CLTSH’, which stands for Community-Led Total
Sanitation and Hygiene.
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CLTSH is about bringing sustainable behavioural change. In general, it works best in

villages that have enthusiastic leadership but it is also dependent on convincing
everyone to change their behaviour. Besides leadership, many other local social,
physical and institutional conditions affect the prospects for CLTSH.
3.3.2.8 CLTSH pre-triggering phase
The facilitators must visit the selected kebele or kebeles prior to the community
triggering. This visit is mainly to estimate the size of the community and its
population but also to identify the dirtiest areas in the vicinity that are most
frequently used for open defecation. This must be done with the community, possibly
using a participatory mapping process.
3.3.2.9 CLTSH triggering phase
Community triggering happens at a gathering of the local inhabitants who come

together to have a dialogue about concerns related to open defecation. The purpose of
this dialogue is to bring collective action against the open defecation behaviour.
Triggering refers to the moment when the whole community shares a sense of disgust
and shame about open defecation. The facilitator helps them to come to the
realisation that they quite literally will be eating one another’s shit if open defecation
continues.
In particular, the aim of the triggering phase is to reach agreement about actions to be
taken. The actions will be governed by bylaws developed by the community. The
final output of triggering is a community-based action plan, which includes an
agreed schedule and set of activities that everyone in the community commits to
participating in. This involves construction of latrines with handwashing facilities
and commitment from everyone that they will use the new facilities at all times.
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3.3.2.10 CLTSH post-triggering phase
In this phase, participatory review meetings should be organised by community

members and facilitated by Health Extension Workers or other CLTSH-trained
facilitators. The main purpose of these sessions is to review the progress made
towards achieving the objectives of the plan. A sanitation map prepared during
triggering can be used again to follow the progress made. Households that have
constructed and started using a latrine are marked on the sanitation map. Comparing
this with the original map can show the progress made in the reduction of open
defecation sites.
Fig 3.2.7: Producing a sanitation map using a community participatory approach
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3.3.3 Health-Risk Reduction and Safety Practices

The rationale for employer sponsorship of health promotion programmes includes
preventing loss of worker productivity due to avoidable illnesses and disability and
their associated absenteeism, improving employee well-being and morale, and
controlling the costs of employer-paid health insurance by reducing the amount of
health care services required. Similar considerations have stimulated union interest
in sponsoring programmes, particularly when their members are scattered among
many organisations too small to mount effective programmes on their own.
The workplace affords unique opportunities to promote the improved health and
well-being of the workers by,
• Integrating the health protection and promotion programme into the
organisation's efforts to control occupational diseases and injuries
• Modifying the structure of the job and its environment in ways that will make
it less hazardous and less stressful
• Providing employer- or union-sponsored programmes designed to enable
employees to cope more effectively with personal or family burdens that may
impinge on their well-being and work performance (i.e., modified work
schedules and financial assistance benefits and programmes that address
alcohol and drug abuse, pregnancy, child care, caring for elderly or disabled
family members, marital difficulties or planning for retirement)
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3.3.3.1 Programme Objectives and Ideology
The basic objectives of the programme are to enhance and maintain the health and
well-being of employees on all levels, to prevent disease and disability, and to ease
the burden on individuals and the organisation when disease and disability cannot be
prevented.
3.3.3.2 Programme Components
a) Needs assessment
While the alert programme director will take advantage of a particular event that will
create interest in a special activity (e.g., the unexpected illness of a popular person in
the organisation, reports of cases of an infectious disease that raise fears of contagion,
warnings of a potential epidemic), the comprehensive programme will be based on a
more formal needs assessment. This may simply consist of a comparison of the
demographic characteristics of the workforce with morbidity and mortality data
reported by public health authorities for such population cohorts in the area, or it
may comprise the aggregate analyses of company-specific health-related data, such
as health care insurance claims and the recorded causes of absenteeism and of
disability retirement.
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3.3.3.3 Programme Elements
A comprehensive health promotion and disease prevention programme includes a

number of elements, such as the following:
1. Promoting the programme: A constant stream of promotional devices, such as

handbills, memoranda, posters, brochures, articles in company periodicals, etc., will
serve to call attention to the availability and desirability of participating in the
programme. With their permission, stories of the accomplishments of individual
employees and any awards for achieving health promotion goals they may have
earned may be highlighted.
2. Health assessment: Where possible, each employee's health status should be

assessed on entering the programme to provide a basis for a "prescription" of personal
objectives to be achieved and of the specific activities that are indicated, and
periodically to assess progress and interim changes in health status. The health risk
appraisal may be used with or without a medical examination as comprehensive as
circumstances permit, and supplemented by laboratory and diagnostic studies.
3. Activities: There is a long list of activities that may be pursued as part of the
programme. Some are continuing, others are addressed only periodically. These
activities may be divided into the following overlapping categories,
a. Clinical Service: These require health professionals and include, medical

examinations; screening programmes; diagnostic procedures such as
mammography; Pap smears and tests for cholesterol level; immunizations and
so forth. They also include counselling and behaviour modification in relation
to weight control, fitness, smoking cessation and other lifestyle factors.
b. Health Education: Education to promote awareness of potential diseases, the

importance of controlling risk factors, and the value of maintaining healthy
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lifestyles, for instance, through weight control, fitness training and smoking
cessation. Such education should also point the way to appropriate
interventions.
c. Guidance in managing Medical Care: Advice should be given with regard to

the following concerns: dealing with the health care system and procuring
prompt and high-quality medical care; managing chronic or recurrent health
problems; rehabilitation and return to work after disease or injury; treatment
for alcohol and drug abuse; prenatal care and so on.
d. Coping with Personal Problems: Coping skills to be developed include, for

example, stress management, pre-retirement planning and outplacement.
Help can also be provided for workers who need to deal with work and family
problems such as family planning, prenatal care, dependent care, parenting,
and so forth.
e. Workplace Amenities and Policies: Workplace features and policies

supplementary to those addressing occupational health and safety activities
would include personal washing-up and locker facilities, laundry service
where needed, catering facilities offering nutrition advice and helpful food
choices, and the establishment of a smoke-free and drug-free workplace,
among others.
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3.3.3.4 Healthy Policies
Recognition is increasing that organisational policy and social norms are important
determinants of health and of the effectiveness of health improvement efforts. For
example, limiting or banning smoking at the workplace can yield substantial declines
in per capita cigarette consumption among smoking workers. A policy that alcoholic
beverages will not be served at company functions lays out behavioural expectations
for employees. Providing food that is low in fat and high in complex carbohydrates in
the company cafeteria is another opportunity to help employees improve their health.
Ergonomic design is an important determinant of worker health and involves more
than just the physical fit of the employee to the tools employed on the job.
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3.3.4 Breast Self-Examination

Midwives are in a prime position to provide advice and make significant
contributions to women’s health in areas such as nutrition, breast feeding and
smoking cessation. However, there is one area that requires more attention in
midwifery practice, that is breast awareness. Breast Cancer Awareness Month – run
nationwide every October by Action Breast Cancer – highlights the responsibility of
midwives to raise awareness about breast health among their patients.
Breast cancer contributes significantly to mortality and morbidity rates in Ireland and
is the greatest cause of premature deaths from cancer in women. With breast cancer,
improvements can be made in health and quality of life through early detection,
screening, diagnosis and treatment. Midwives therefore have a compelling
responsibility to teach women how to do breast self-examination and to encourage its
practice.
There are about 200 different types of cancer and breast cancer is the second most
common in Ireland. The disease is rare in women under 30, however women of all
ages should always be breast aware. Breast cancer is now seen as being preventable
in many cases due in part to greater health promotion, which focuses on primary
prevention through health education and support for behavioural changes, such as
frequent breast self-examination; and secondary prevention through early detection
and treatment. Some breast cancer risk factors such as early menstruation and late
menopause, are not open to intervention, but others such as oral contraceptive use,
obesity, excessive alcohol consumption, use of hormone replacement therapy and the
protective effect of breast feeding, should be highlighted to women by midwives and
other healthcare professionals, and through publicly available information from the
HSE.
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Being breast aware means knowing what is normal for a person so that any unusual
changes will be recognised. In Ireland, charities like Action Breast Cancer have
developed websites with information regarding breast awareness. Action Breast
Cancer has also distributed a leaflet entitled ‘Know your breasts’ which informs
women how to self-examine their breasts. Leaflets enable women to access and utilise
information, with explanatory diagrams, at a pace that suits. They are one of the most
common methods of providing information regarding breast awareness and
although they have shown some consistent results in raising awareness, there is less
evidence that leaflets can change behaviour. Midwives play a crucial role in breast
health promotion. They must educate women about the functioning of the breast,
encourage self-examination, and inform women that a healthy lifestyle with a varied
diet and exercise plays an important role in preventing cancer.
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3.3.5 Conclusion
There is no doubt of the efficacy of immunisations in preventing infectious diseases
or of the value of good occupational health and safety programmes in reducing the
frequency and severity of work-related diseases and injuries. There is general
agreement that early detection and appropriate treatment of incipient diseases will
reduce mortality and lower the frequency and extent of residual disability from many
diseases. There is growing evidence that elimination or control of risk factors will
prevent or, at least, substantially delay the onset of life-threatening diseases such as
stroke, coronary artery disease and cancer. There is little doubt that maintaining a
healthy lifestyle and coping successfully with psychosocial burdens will improve
well-being and functional capacity to achieve the goal of wellness defined by the
World Health Organisation as a state beyond the mere absence of disease. Health
promotion and Education for effective campaign is used to improve immunisation
program, sanitation, health-risk reduction and safety practices and Breast
self-examination etc., play very important role.
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Summary
• Barriers to accessing the immunisation service include issues that can be

resolved by better communication. These barriers include lack of knowledge
about the need for immunisation or the need to return for further doses, or
about the time and location of immunisation sessions; fear of adverse
reactions is another barrier that good communication can overcome.
• Behaviour Change Communication (BCC) activities should be an integral part

of your planned immunisation strategy; the planning process involves a
communication needs assessment, the definition of communication objectives,
strategies and activities, implementation, and assessment of outcomes
through monitoring and evaluation.
• Priority behaviours should be identified in order to develop a focused

behaviour change intervention that can contribute to sustainable change in
the health condition of the urban population. Specific priority behaviours for
WASH interventions should be selected based on a situation analysis.
• Based on behaviour analysis, a combination of four main intervention

approaches may be pursued to increase, encourage and sustain a change in
sanitation hygiene and health practices – individual behaviour change
communication, social change communication, social mobilisation and
advocacy.
• Educate women can encourage breast self-examination and inform women

that a healthy lifestyle with a varied diet and exercise plays an important role
in preventing cancer.
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Case Study
The Tonga people of southern Zambia are used to disruptions in their way of life. In
the colonial era, European farmers settled on Tonga lands when the main road and
railway line were built through their territory from what is now Zimbabwe to the
capital, Lusaka, and many people changed their lifestyle and went to work for them.
Eighty-year-old Chief Mapanza of Choma remembers those days and the way the
Europeans imposed their ideas, even in intimate domestic matters: ‘The settlers forced
the villagers to dig pit latrines and instructed messengers to inspect the villages. Those that did
not have pit latrines were severely punished.’
Chief Mapanza thinks this is why, in recent decades, people in Choma would not
accept sanitation. ‘When you use force, people will resist. That kind of resistance could go on
for generations. Perhaps this is what has happened in our country.’ Whatever the reason for
the long persistence of objections to toilets in this corner of Zambia, in 12
communities in Choma district that resistance has now been broken. And the role of
the traditional rulers has been central to success.
The new campaign began in November 2007, when UNICEF introduced the
‘community-led total sanitation’ (CLTS) methodology into the communities. Another
local ruler, Chief Macha, subsequently one of the most energetic of exponents,
recalled the first time he encountered people discussing the CLTS strategy in Choma
Hotel. ‘I was horrified to overhear someone from UNICEF talking about shit, and I confronted
him saying that UNICEF must look at the welfare of children, and not at shit. But I was
persuaded to join the discussion, and I came to understand what it was all about.’ Since
then he has taken the lead in Macha’s 100 communities.
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Chief Macha was one of over 50 specially- trained facilitators for CLTS. After the
training, meetings were held in each community. The inhabitants were invited to
walk around the neighbourhood, identifying places used for ‘open defecation’, and to
talk openly about their personal habits. This is done in a humorous manner but the
message hits home. Once people realize that particles of faeces left lying about get
onto feet, hands, utensils, and into drinking water, and ultimately into peoples’
mouths and stomachs, a sense of shame and disgust overtakes them. For the first
time, people in Macha really understood what toilets could contribute to clean and
respectable living. There can be no pussyfooting: the ‘s’ word — normally taboo —
must be used. Chief Macha’s campaign, complete with T-shirts, is
uncompromisingly entitled: ‘No shit please! One family, one toilet’.
No Toilet Subsidies
An important element of the CLTS strategy is that while every effort is made to
encourage and advise the communities on technical issues, no subsidy is offered for
toilet building. Their problem must be owned by the community and solved by the
community.
Experience has shown that where toilets are constructed in people’s compounds by
public health engineers, they may not be used — or at least, not for their intended
purpose — unless the families in question are convinced that a visit to a dark little
cabin with a pit is prefer- able to a walk in the fresh and breezy open air. That act
of persuasion and conviction has often been missing. So, the CLTS approach gets
away from building toilets for people, on the basis that where real conviction has
been brought about, people will be happy to build toilets for themselves.
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However, if people whose cash incomes are low and for whom a toilet represents a
major investment are to not only be convinced of the merits of a toilet but actually
build one, the cost has to be within their means. In the past, the only ‘officially
approved’ toilets in Zambia were ‘Ventilated Improved Pit’ (VIP) toilets, and toilets that
flush, both of which are expensive. Now, under the government’s national water and
sanitation programme put in place to reach the Millennium Development Goals, the
definition of ‘adequate sanitation’ has been widened. Simpler pit toilets are included,
notably those with a smooth squatting platform, drop-hole and lid. Correspondingly
the costs of toilet installation have been dramatically reduced. So now it is more
practicable to promote sanitation to new users without having to offer a subsidy.
The CLTS approach engenders a sense of shame and disgust in relation to their old
unsanitary ways which ‘triggers’ the members of the community into abandoning
‘open defecation’. At the meeting, time is spent working out how much excreta is
regularly deposited in their neighbourhood and what its threats consist of. The costs
of poor sanitation are also calculated in relation to medical bills and lost
productivity. When they have resolved to abandon open defecation, a demonstra-
tion is made of how to construct a simple pit toilet, along with its costs. A village
Sanitation Action Group (SAG) is formed, consisting of five men and five women,
who assume the responsibility of assisting households to build their toilets and
monitoring their use. Where a household is particularly poor or debilitated, the SAG
will organize help.
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31
Amazing Results in Two Months
The CLTS programme in Choma began in November 2007. Two months later an
evaluation was undertaken. Within a population of over 4,500, sanitation coverage
had risen from 23 per cent to 88 per cent. More than two- thirds of the toilets
constructed met the government’s definition of ‘adequate’. In three- quarters of the
villages, there was no visible excreta, and these were accordingly testified as ‘open
defecation free’.
Chief Macha explains what he believes has happened: ‘The issue of sanitation is not new
in my area. However, the approach has given us a boost and the people have enthusiastically
embraced it. This is because the villagers are not being asked to construct expensive toilets they
cannot afford. All the material and the labour is locally available. It is not UNICEF’s
responsibility to build toilets, but ours. They are just here to support us and to give us
professional advice. I believe every household in Macha will have a toilet by the end of 2008.’
Chief Macha has even threatened that those of his subjects without a toilet at that
stage will not be allowed to shit.
Although sanitation has been promoted in rural Africa for many years, until very
recently there has been a total absence of anthropo- logical research into beliefs,
customs and behaviours concerning excretory behaviour. In crowded urban
environments, and settings where migrant workers were familiarized with toilets in
hostels or other living accommodation, people adopt them relatively easily, but not
in rural areas. The poor results from many programmes — not only in Africa but in
other parts of the world — have finally led to efforts to understand these issues
better. In traditional settings that have not changed much over the years, there are
rules about where and when men and women are supposed to ‘go’, and what is
acceptable behaviour. Breaches of these rules lead to penalties on offenders.
Therefore, in these old-fashioned ‘sanitation systems’, elders and leaders also played
the important role today assumed by Chief Macha and other headmen in the trial
Education
32
communities in Choma. The appeal to community status and self-respect seems to

resonate, where ‘better health’ messages did not.
One Compound, Five Toilets

One village headman has proved a particular role-model and exemplar. Joseph
Mwaanga Simulangu’s compound in Chief Macha’s area about 60 kilometres west of
Choma town has four houses, four kitchens and five toilets. The four houses belong
to his four wives and their children. Why five toilets? ‘Four are for each of my wives.
The fifth is mine,’ explains the 81-year-old traditional leader. Headman Simu- langu
described how, before the programme, the family of 30, which includes his 25
children, used one pit latrine. ‘The toilet was always dirty and stinky. It filled up too
quickly. Thus we found it more convenient to go into the bush,’ he said.
At night when it was too dark, too scary and too unsafe to go into the bush, they
went behind the house. ‘All you did was carry a hoe and dig a hole and cover it up after
you finished defecating. But this wasn’t very good because the holes were shallow and they
were easily dug up by pigs, dogs and even chickens which ate the faeces,’ the headman said.
When it was explained how flies transferred germs from faeces to food, Simulangu
understood why there were frequent outbreaks of diarrhoea in the family. The only
way he could ensure that all four wives and offspring would change their habits was
to give them all their own facility. We all know how unpleasant it is to clean other
people’s detritus, should someone ‘miss’ the drop-hole: each wife will have to
discipline her children. The headman also found it difficult to get used to being seen
going into his ‘toilet house’, but he has gradually conquered his inhibitions.
The question of sustainability — will people continue to use their toilets if they
become dirty or full and need emptying or replacing? — is a critical one. Chief
Macha regards the current activity as only the first stage in the process. Where
construction is not well-done, the toilet pit may collapse in the rainy season. ‘We need
to move towards building permanent structures which are safe. If all families work together, we
will build better communities. My vision is to build a better Macha.’ The ‘No shit please!’
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33
campaign has mobilized his sense of leadership. ‘Now I understand what it means to be a
chief,’ he says. ‘To be a chief is to be a community leader. Sometimes it is good to be insulted
over your convictions, because you are leading the people.’
Impacts of Toilet
The impact of the toilet revolution has already had an effect on disease rates and on
school attendance. The local hospital, Macha Mission Hospital, has noted a reduction
in diarrhoeal disease cases since last year. Clinical care manager Abraham Mhango
points out that the reduction in drugs and treatment represents a saving: ‘The money
can be used on other areas of health care, such as respiratory tract infections. This means our
health care will be cost-effective’.
Schools have been a special target of the UNICEF-assisted programme. At Choma

Central Basic School, head teacher Phanuel Hachibzibe attributed improved
attendance to the project. Cases of absenteeism due to diarrhoeal disease have gone
down. ‘We monitor absenteeism every day, and we have seen tremendous
improvement.’ At Siamambo Basic School 10 kilometres south of Choma, new toilet
blocks with both pits and urinals, and hand-washing facilities, have been built for
boys and girls, and their walls have been decorated with colourful murals and
sanitation messages painted by the pupils themselves. The pictures and the
inscriptions implore pupils to wash their hands after they use the toilet. Mercy
Banda, a teacher at the school, says that both staff and pupils have become much
more hygiene conscious. Jane Siabbeula, a 15-year-old student in Grade 9, has
become an assiduous hand-washer. ‘I look at the walls every day and I’m reminded about
keeping healthy and clean,’ she says.
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34
The project in Choma is taking place within the framework of the national
programme for water and sanitation, and the government’s aim is to have a toilet in
every household by 2030. According to a 2005 survey on living conditions, more
than 30 per cent of rural Zambians, or 2 million people, did not use a toilet. UNICEF
and WHO estimate rural sanitation coverage to be lower than this, at 52 per cent,
with wide geographical disparities. Mobilizing all these people is going to be a major
task, especially in remote parts of the country where sanitation can be as low as 17
per cent. But officials who have visited Macha to inspect the ‘toilet revolution’ are
impressed by the possibilities.
Chiefs from adjoining neighbourhoods have already introduced the CLTS approach
within their chiefdoms, thereby expanding the ‘One family, one toilet’ campaign to
cover all 480 villages and 173,000 people in Choma district. But everyone is aware
that momentum must not be allowed to flag. Much will depend on whether the same
energy injected by Chief Macha will be emulated elsewhere. CLTS introduction in
more districts and provinces is another matter yet. There is still a long way to go.
Questions
1. Who started CLTS and in which Year in Zambia?
2. Describe the role of CLTS in Sanitation?
3. What is the role of Local government to improve sanitation?
4. Describe the role of village‐level actors in CLTS?
5. What is triggering in CLTS techniques?
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Bibliography
E-References
• Glanz, K., Rimer, BK., & Viswanath, K. (2008) Health Behaviour and Health
Education: Theory, Research and Practice, 4 Edition Jossey-Bass Publishers.
• DiClemente, RJ., Crosby, RA. and Kegler, MC. (2009) Emerging Theories in
Health Promotion Practice and Research. 2nd Edition, Jossy-Bass Publishers.
External Resources
• https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=5337
0&printable=1
• https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=8061
5&printable=1
• http://www.ilocis.org/documents/chpt15e.htm
• https://www.inmo.ie/MagazineArticle/PrintArticle/10216
Education
36

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Social and Behavioural Health

Theoritical and Conceptual Issues in Health

Module describes the ecological approach nature of health promotion in providing

Health Promotion and Health Education

Health Program Planning, Implementation and Evaluation

Unit Table of Contents

• Describe how one would plan and choose appropriate communication

• Understand appropriate communication strategies to promote immunisation

There is no doubt of the efficacy of immunisations in preventing infectious diseases

Fig 3.3.1: Key EPI Operations

Immunisation programmes may be unsuccessful if incorrect or inadequate

• Improve relations between you as a Health Extension Practitioner and the

3.3.1.1 Planning a Communication Activity

A communication strategy should be included in your annual EPI action plans.

Fig 3.3.2: Planning process for Effective Communication

3.3.1.2 Strategies and Activities

Behaviour Change Communication (BCC) is a process of developing communication

3.3.1.3 Common methods of BCC in Immunisation

Advocacy is a process or activity that aims to influences politicians, policy-makers

3.3.1.5 Community Mobilisation

Community mobilisation is a process of gaining the involvement of everyone in the

3.3.1.6 Community Conversation

One of the ways in which it is possible to influence behaviour is through

Fig 3.3.3: Community Conversation

Such a conversation will be successful when everyone is given the opportunity to be

believe their opinions will be heard.

3.3.1.7 Factors to be considered for successful Community Conversations

The factors include,

• Decide on the purpose of the conversation and advertise it widely.

3.3.1.8 Interpersonal Communication

Interpersonal communication is a term for face-to-face interaction with an

3.3.1.9 Interpersonal Communication Skills

The important interpersonal communication skills include the following steps,

Fig 3.3.4: Active Listening

3.3.1.10 Asking Questions Sensitively

What questions might you ask a mother in one-to-one interpersonal communication

Asking about a caregiver’s worries about immunisation is an example of an open

3.3.1.11 Meeting with target audiences to promote EPI activities

3.3.1.12 Meeting with Community Leaders

3.3.1.13 Meeting with Parents

3.3.1.14 Meeting with NGOs and other partners

3.3.1.15 Meetings with special groups

3.3.1.16 Negative rumours about Immunisation

Rumours about bad consequences of immunisation often circulate in communities. If

Fig 3.3.5: Supplying water in closed containers with secure lids

3.3.2.1 Behavioural barriers to improving Hygiene and Sanitation

The behavioural barriers may be the result of personal or socio-cultural factors, or

3.3.2.2 Personal barriers

Personal barriers include those resulting from lack of knowledge or awareness.

3.3.2.3 Socio-cultural barriers

Fig 3.2.6: A women cleaning latrine

3.3.2.4 Economic barriers

3.3.2.5 Environmental barriers

There are often environmental constraints to provision of adequate latrine facilities.

3.3.2.6 Interventions to promote improved Hygiene and Sanitation

Social change communication aims to increase community involvement in selecting

3.3.2.7 Community-Led Total Sanitation (CLTS)

It is a method for mobilising communities to completely eliminate open defecation by

CLTSH is about bringing sustainable behavioural change. In general, it works best in

3.3.2.8 CLTSH pre-triggering phase