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Table 1 The Theory of Change for a Classic Community Health Club Intervention – as used in Rusizi District, Rwanda

From: The value of monitoring data in a process evaluation of hygiene behaviour change in Community Health Clubs to explain findings from a cluster-randomised controlled trial in Rwanda

Causes (Determinants)EffectResultsExpected inputs (Assumptions)OutputsOutcomes
MACRO LEVEL: National / Provincial and District
 1.1.i. Fragile State -breakdown of economy, law, order and securityii. Government structures are weakened or ineffectualiii. Emergency humanitarian programmes take over from normal state structuresiv. Political enabling environment. Government (MoH) provides normal services /supportv. Political enabling environment: NGOs / funding agencies support national government CBEHP programvi. Funding: NGOs and Agencies are able to provide financial and advisory support to districts
 1.2.i. Lack of a clear Environmental Health (EH) Strategy within MoH policy / government reshuffle or changes in administrationii. Environmental Health Department (EHD) is weak and doesn’t manage the WASH sectoriii. Uncoordinated WASH sector /many different strategies and conflicting models of changeiv. EH Policy: Development of a national Road Map for CBEHPP using CHCs in each village with clear methods to achieve behaviour changev. Higher political visibility - EHD manages the CBEHPP with support for MoH by donor agencies and NGOsvi. WASH programs can be scaled up and CHC started throughout country
 1.3.i. Lack of standardised training materialsii. Difficult to train trainers effectivelyiii. No Core -Trainer of trainers teamiv. Training Material: Develop CBEHPP manual and tools to be readily availablev. National Core Trainers trained in CBEHPP to train all districts at every levelvi. Sustainable human resource in country to implement CBEHPP
 1.4.i. Lack of WASH strategy in Districtii. Weak budgetary support & inadequate training for EHOsiii. District prioritises curative over preventative EHD servicesiv. Training Trainers: EHOs and district leadership understand the rationale for starting CHCv. EHOs monitor CHC and have to account for progress on WASH indicators in CBEHPPvi. Sustainable district planning and monitoring systems ensuring CHCs continue to function
 1.5.i. Lack of transport for EHOs to monitor CHCsii. Community monitoring does not take placeiii. Little data on hygiene/ sanitation in villagesiv. Transport: EHOs are provided with reliable motorbikes to reach villages so as to monitor CHCsv. Mobile EHOs are able to monitor CHCs easilyvi. SDG WASH targets are tracked and therefore more likely to be met at district level
 1.6.i. Low profile of EHD in Districtsii. Not enough EH staff in districtiii. Inability of MoH to properly monitor WASHiv. Supervision: EHOs supervise CHC facilitators in communityv. CHC facilitators well supported in ensuring active and effective CHCvi. High Profile of EHD in district
 1.7.i. Lack of Meeting venueii. Difficult to hold CHC sessions in heavy rainy seasoniii. Low CHC attendance due to meeting held outside in rainiv. Timing / Duration: 24 CHC health sessions have to be timed to be held in the dry seasonv. High Completion of training – no excuse for members not to complete trainingvi. High coverage of well informed CHC members and active group in all villages
MICRO LEVEL: Village and household
 2.1.i. Poorly organised communityii. Low levels of hygiene and sanitationiii. High diarrhoea rates and resistence to changeiv. Community Mobilisation: A CHC is started in every villagev. Peer support for all households to change with social pressure to meet hygiene standardsvi. a80% housholds are in a CHC sharing same attitudes, beliefs, values.
 2.2.i. Lack of informed leadershipii. Poor decision makingiii. Lack of training and monitoring of hygiene standardsiv. Quality Training: CHC facilitators / leaders are trained in participatory CHC approach & CBEHPPv. CHC Facilitator within village / village leaders trained to monitor hygiene standardsvi. a50-100 households are active members within a functional CHC
 2.3.i. Lack of learning opportunity within villageii. Inadequate knowledge to prevent diseaseiii. Little community action to improve WASH facilitiesiv. Exposure: 24 CHC health sessions are offered weekly for at least 6 to 12 monthsv. Improved understanding how to prevent disease by safe hygiene and sanitationvi. a80% of households with knowledge of how to manage family health
 2.4.i. Inertia and lack of interest in hygiene & prevention of diseaseii. Not prioritising ways to protect their familyiii. Poor hygiene & little effort/ expenditure on improving WASH facilitiesiv. Visibility: Model Home competitions are held to increase interest & attract high level of participationv. High priority in the investment of time and energy to improve hygiene facilities and change behaviourvi. a80% uptake of safe hygiene practice and safe sanitation facilities
 2.5.i. High risk hygiene practices and sanitationii. High levels of preventable diseaseiii. High infant and child mortalityiv. Reinforcement: CHC continue to meet after the CHC training is completev. Higher social cohesion and increased support for vulnerable individualsvi. Improved social capital, family healthb and standard of living.
  1. aThe target of intervention varies depending on the intervention design – This table shows the CBEHPP target in Rwanda. Over 80% compliance of recommended practices (safe drinking source, safe water storage, safe sanitation, zero open defecation, hand washing facility, soap for handwashing, pot racks /clean pots, solid waste managed, individual cups/plates, safe food hygiene, dedicated clean kitchen, grey water drainage
  2. bFor the Stage 1 Training in CHC which focuses on WASH mainly a decrease in diarrhoea, skin disease, bilharzia, intestinal parasites is possible