.

Acknowledgements

This training manual and associated training materials were developed from (and directly replicate certain sections of) the CARE Sierra Leone training Manual (2005). GOAL is highly appreciative of the sharing of these materials by CARE, and technical guidance and inputs offered during the pilot.

Thanks to Brima Kabba, Mohammed Turay and Will Tillett who assisted considerably in the production of this GOAL manual.

Members of the District Health Management Team (DHMT), particularly the District Medical Officer (DMO) and Environmental Health Superintendent have been very supportive in the development of this pilot. The International Rescue Committee (IRC) has also provided valuable support and inputs, and both IRC and the DHMT will continue to be key partners in the delivery, monitoring and lessons learning of this pilot. This is well appreciated.

Thanks to the Chiefdom Authorities and Chiefdom Health Overseer(S) for their involvement in the project, together with the Peripheral Health Unit (PHU) staff.

Most importantly, thanks for the time and dedication of the Peer Supervisors and Community Health Workers for their commitment for delivering the trainings and reporting, and tirelessly working to improve the health of the people of Sierra Leone

COMMUNITY

HEALTH CLUB

FACILITATOR

MANUAL PHASE 1 TOPICS (Club formation, Basic health

concepts, health seeking behaviors, WASH,

communicable diseases)

ABSTRACT This manual is to guide the Community Health

Works, Peer Supervisors, and supporting

personnel in the delivery of a pilot Community

Health Club project in Kenema, Sierra Leone.

This manual covers ‘Phase 1’ topics. The pilot is

being implemented during 2015-2016 by GOAL

and the Ministry of Health & Sanitation, with

financial support from IrishAid.

GOAL 2015

Acknowledgements

This training manual and associated training materials were developed from (and directly replicate certain sections of) the CARE Sierra Leone training Manual (2005), titled ‘Communicating Health, Communicating Rights’. GOAL is highly appreciative of the sharing of these materials by CARE.

Thanks to George Kabo, Mohammed Sama, and Mohammed Turay for their inputs, and particularly to Will Tillett, who led in the production of this GOAL manual.

Thanks to the GOAL Health Club team, Boima Kpuagor, Yambasu Koker, Loti Chigingoma and Vijay Narayan for their valuable inputs, and Else Kirk for driving the idea of the Health Clubs pilot into a reality. Thanks to IrishAid for funding of this work.

Members of the Kenema District Health Management Team (DHMT) have been very supportive in the development of this pilot. The International Rescue Committee (IRC) has also provided valuable support and inputs.

Thanks to the Chiefdom Authorities and Chiefdom Health Overseer(S) for their involvement in the project, together with the Peripheral Health Unit (PHU) staff.

Most importantly, thanks for the time and dedication of the Peer Supervisors and Community Health Workers for their commitment for delivering the trainings and reporting, and tirelessly working to improve the health of the people of Sierra Leone

Disclaimer

The contents of this manual that utilize aspects of the Care Sierra Leone Manual (and flash card pictures) were done so with consent of Care Sierra Leone staff.

Some pictures and drawings contained in this manual and accompanying flash cards were taken from various internet resources and SMAC tools, rather than developing specific drawings only for the purpose of this pilot. This was to minimize costs for the pilot project, and in light of the fact this manual has not been developed for commercial purposes. The sources have been referenced.

Contents

Section 1. The Club Concept, Establishing & Managing the Club, & How to be a Good Facilitator........................1

Introduction ...............................................................................................................................................................1

How to Use this Manual, and Run Participatory and Fun Sessions .........................................................................6

How to Establish & Manage the Clubs ......................................................................................................................9

Roles & Responsibilities.........................................................................................................................................9

Establishing the Clubs ......................................................................................................................................... 10

Session 1 - Community Mobilization and Discussing the Establishment of the Club ................................... 10

Session 2- Defining the Club Purpose, Agreeing Ground Rules, Building Communication Skills ................. 10

Section: 2 Plans for Individual Sessions for Phase 1 .............................................................................................. 14

Module 1. Mobilization and Forming the Clubs .................................................................................................... 14

Session 1: Community Mobilization & Problem Definition .............................................................................. 14

Session 2. Defining the Club Purpose, Agreeing Ground Rules, Building Communication Skills ..................... 16

Module 2. Basic Health Understanding, Monitoring, & Health Seeking Behaviours ........................................... 21

Session 3: Problem definition on health issues, health club reporting and health monitoring in the

community .......................................................................................................................................................... 21

Session 4: Body Mapping, Germ Theory & Transmission .................................................................................. 26

Session 5: Health Seeking Behaviors .................................................................................................................. 30

Module 3. Personal Hygiene & Health ................................................................................................................... 32

Session 6: Handwashing ..................................................................................................................................... 32

Session 7: Personal Hygiene & Skin Diseases .................................................................................................... 36

Session 8: The Body’s Immune System ............................................................................................................. 42

Module 4. The Safe Water Chain............................................................................................................................ 45

Session 9: Water Sources .................................................................................................................................... 45

Session 10: Water Transport, Treatment & Storage.......................................................................................... 50

Module 5: Total Sanitation (“Amu Kpoi Lowu”) .................................................................................................... 55

Session 11: The Importance of Total Sanitation (1) ........................................................................................... 55

Session 12: Planning for Total Sanitation (“Amu Kpoi Lowu!”) ........................................................................ 59

Session 13: Building a Hygienic Toilet ................................................................................................................ 67

Session 14: Total Sanitation 2. Child & Farm Sanitation ................................................................................... 75

Module 6: Hygiene .................................................................................................................................................. 79

Session 15: Domestic and compound hygiene .................................................................................................. 79

Session 16: Food Hygiene ................................................................................................................................... 83

Module 7: Key Communicable Diseases ................................................................................................................ 88

Session: 17 Diarrhoea ......................................................................................................................................... 88

Session 18: Intestinal Worms ............................................................................................................................. 94

Session 19: Malaria ............................................................................................................................................. 98

Session 20: Acute respiratory infections (ARIs) ............................................................................................... 102

Session 21: Lassa fever ..................................................................................................................................... 107

Session 22: Onchocerciasis & Schistosomiasis ................................................................................................. 113

Session 23. Ebola ............................................................................................................................................... 118

Module 8. Sustaining Total Sanitation & Hygiene Practices ............................................................................... 123

Session 24: Using & Maintaining the Toilet ..................................................................................................... 123

Session 25: Revision / Quiz ................................................................................................................................... 127

Acronyms Table

Acronym Detail

ARI Acute Respiratory Infection

CH Club Community Health Club (not called CHC due to confusion with Community Health Centers)

CHC Community Health Centre

Chiefdom HO Chiefdom Health Overseer

CHP Community Health Post

CHW Community Health Worker

CLEA Community Led Ebola Action

CLTS Community Led Total Sanitation

CSL Club Savings & Loans

DHMT District Health Management Team

HWTS Household Water Treatment & Storage

IEC Information, Education Communication

IRC International Rescue Committee

MCHP Maternal & Child Health Post

PHU Peripheral Health Unit

VSL Village Savings & Loans

Section 1. The Club Concept, Establishing & Managing the Club,

& How to be a Good Facilitator

Introduction Brief Background

Sierra Leone is a country that is very well-endowed with high rainfall, widespread water resources, fertile

soils and huge agricultural potential. However, despite these significant blessings, it remains the 8th

poorest country in the world on the UN Human Development Index. With an estimated 46,000 deaths

per year that could otherwise be prevented by improved drinking water supply, sanitation and hygiene,

there is an overwhelming need and opportunity to substantially reduce this death toll, through an

expanded public health approach that should include all preventable diseases. The healthcare system in

Sierra Leone is also weak, and ‘alternative’ health seeking behaviors such as traditional healers and

‘Quacks’ presents challenges. The impact on hygiene behaviors from existing approaches in Sierra Leone

(Community Lead Total Sanitation as it has been implemented to date) may not be sustained through

time, and the focus is relatively narrow to cover comprehensive water-related disease prevention.

As the level of literacy is so low, it makes sense to adopt a Community Health Promotion approach that

takes the time and provides sufficient face-to-face interaction in order to affect behavior change for a

whole raft of health and hygiene topics. This is the concept of the Community Health Club (CH Club)

approach.

Through a participatory process of activities using specialized visual aids and techniques, the whole

community becomes conversant with the causes, transmission and prevention of a wide range of

communicable diseases, together with an increased awareness of maternal and child health, reproductive

health and nutrition issues. The clubs develop a ‘culture of health’ within the communities, and mobilize

action to improve the community health status and impart measures to prevent and monitor diseases.

This process that enables informed group-consensus and decision making is a form of capacity building

that aims to increase trust, reciprocity and ultimately to build Social Capital within a village. CH Clubs are

voluntary organizations, open to all ages, levels of education and status, and to men and women, free of

charge.

CH Clubs have been implemented in many countries across Africa. Care International has implemented

CH Clubs in Sierra Leone since 2005, through direct implementation by their field officers. There is appetite

to pilot an evolved approach, delivered through the Ministry of Health & Sanitation (MoHS) Community

Health Workers (CHWs), expanding the topics covered, and introducing elements such as Village Savings

& Loans (VSL) and Sanitation Marketing. Using Community Health Workers to facilitate these clubs builds

their role and credibility within the community on health issues, and helps to strengthen the link with the

community and health services. A project funded by IrishAid has been developed for implementation of

an adapted CH Club pilot in Kenema District in 2015-2016.

The topics covered in the pilot utilize and build on the CLTS mobilization techniques, and the WASH

aspects of the project could be defined as ‘CLTS+’.

Who is this Manual for, and how is it Laid Out?

This training manual is a guide for CHWs, Peer Supervisors, Chiefdom Health Overseers (CHOs), and NGO

field officers, to facilitate the establishment of CH Clubs, and the roll-out of the ‘first phase’ of topics. This

first phase focusses on establishing the club, WASH and communicable diseases. A subsequent manual

will cover the ‘second phase’ topics, including nutrition, other aspects of maternal and child health, and

reproductive health. Another short document will cover the establishment and management of Club

Savings and Loans functions within the CH Clubs.

The pilot project is complimented by additional sanitation marketing

activities which are not covered in this manual. These activities include the

training and equipping of local masons, assisting with materials for product

demonstration items, and assisting in the promotion of their services to the

clubs and wider community.

This Phase 1 CH Club manual has been based on the Care Sierra Leone 2005 manual, with some aspects

directly lifted from this document, with others developed based on recent experience and information

from sector documents (such as the UNICEF/MoHS CLTS Manual, GOAL WASH Manual). This manual

should be seen as a ‘working document’, to be revised based on experience gained during the CH Pilot in

Kenema. This document has been developed primarily for the use of the Kenema pilot, however it may

be of use for other agencies wishing to adapt their health and hygiene promotion approaches.

It is not intended as a blueprint to be followed line by line, verbatim - it is a supportive resource for

trainers, a guideline. When using this Manual, CHWs on the ground who are working in the communities

are best placed to use and adapt the approach to fit the context and circumstances of communities. The

guide should be used flexibly. The activity and exercise ideas can be adapted to suit the context. Every

trainer has their own style: trainers should feel free to be creative and let their own distinctive facilitation

style emerge, rather than attempting to adhere to approaches to the letter. The most important aspect is

to maintain an empowering, inclusive, fun and participatory approach.

This Manual is about instilling the CHWs with the essential skills, principles, values, attitudes and

behaviours necessary to achieve real community empowerment through the health club approach. This

can only be done through experiential, hands-on learning with communities. The procedures method for

doing each exercise is much less important than the participatory approach itself.

This manual begins with explaining what a CH Club is and some if it’s key features, and then provides

practical guidance for CHWs on how to establish clubs, and how to deliver individual sessions. The

individual topics are organised into ‘modules’ and there is a ‘review quiz’ at the end of the manual. The

individual sessions are each structured to include; purpose, materials list, procedure, notes, questions to

ask and issues to explain, key messages, and actions for members to do as homework.

What is a Community Health Club?

A Community Health Club is a community structure with representatives from all households in the village

that is formed to uphold a high standard of health and hygiene in order to reduce preventable diseases.

Through learning and discussing health issues together, health club members share experience, and build

rapport and trust. This positive peer pressure usually results in a community that can work together on

public health issues, preventing many common diseases. The structured topics cover a wide range of

health and hygiene issues, contributing considerably to adult education of the members. The clubs will

also have a savings and loans function, which can improve the household economic security of members,

allowing them to take loans to improve their health and hygiene status (and for other purposes).

Community health club serves as a change group that is geared towards training and empowering

community members enough to plan, implement, and evaluate sustainable activities in their communities

through a participatory manner.

How does it Work?

Clubs are established by the CHW in their respective communities through mobilizing the community.

Choosing to become a member of the club is entirely voluntary, and no-one should be forced into

participation. Members can be men or women, young or old. To ensure groups are small enough for active

participation by all members, the sizes of the clubs tend to be around 20 members. This number is flexible

based on the set-up of the communities and interests of the club members. The clubs usually have a small

committee, which helps the CHW facilitator to organize the community, follow-up on club tasks, and helps

administer the Club Savings & Loans scheme (CSL). The membership and structure for the committee

should be self-selected by club members, but they do not need to be large, given the clubs themselves

are small.

Each member is given a membership card, and members are taken through a structured syllabus of health

and hygiene topics. The lists of topics are listed on each membership cards. The clubs meet weekly at an

agreed time (timekeeping of the facilitator and members is critical), and run through a specific

topic/session. The CHW normally facilitates these sessions, sometimes with external support (e.g. peer

supervisors, CHO, NGO staff etc). The sessions are approximately 1-1.5 hours long, and are designed to be

fun, engaging and educational. At the end of each session, there is ‘homework’ assigned to the members,

who are to implement an action before the next session. Members who attend the session have that topic

‘signed off’ by the CHW on their membership card. Once the members have covered all the sessions, there

is a formal ‘graduation’ ceremony, whereby members receive framed certificates, there may be prizes,

and there is likely a representative from chiefdom and/or district authorities to attend and congratulate

members for their progress. During the roll-out of the sessions, there may be competitions between club

members (and/or between clubs), such as the ‘healthy home’ competition, where prizes are given for the

most healthy and hygienic homestead. Towards the end of the phase, where needed, the CHW provides

‘remedial sessions’ for those who missed initial sessions to pass that session.

As part of the pilot, the clubs will establish a Club Savings

and Loans scheme (CSL), essentially the same as a VSLA but

specific to club members. This can help encourage

membership and weekly attendance, builds a longer-term

focus of the clubs, and helps introduce financial capacity of

members and the club itself, and frames these funds within

a health and hygiene context. It can help to build the

purchasing power of members to buy hygiene related materials, and the social fund may allow financing

of community health and hygiene related issues. The CSL includes providing metal cash boxes to each

club, which have 3 padlocks, which comes with stationary such as pens and a ledger. Training is given to

the club members/committee on the administration of the CSL scheme.

Multiple ‘syllabuses’ can be covered once the club is established. This pilot will break topics into phases,

with the end of each phase followed by graduation. The Club Savings & Loans (CSL) component would

continue throughout. This manual is to cover Phase 1 topics.

What is the Purpose and Key Benefits of Community Health Clubs?

Community Health Clubs are designed to create a structured mechanism for health and hygiene

promotion and behavioral change at community level, to compliment government health services, and

improve community health. The clubs can evolve into wider community development platforms, and

trigger positive community action on a wide range of topics. Please see below a few of the wide ranging

benefits of the clubs:

It creates health education and promotion as a useful entry point in community development.

It strives for high standards of hygiene and sanitation at household and community levels.

It establishes a strong collective identity and a sense of common purpose.

It allows for integrated programming in WASH, Maternal and Child Health, Reproductive Health,

Nutrition etc to maximize on the health impacts in the communities

It encourages and improves the knowledge at an individual or collective level that allows

communities make better decisions regarding how to prevent and respond –and when to visit the

health center.

Phase 1

- Club formation

- Basic health and hygiene contepts

- Water, sanitation and hygiene (WASH)

- WASH-related communicable diseases

Phase 2

-Maternal and Child Health

- Reproductive Health

- Nutrition

- Income Generating Projects

Phase 3

- ??

It encourages active participation of women, as they are recognized as equals by sitting side by

side with men in weekly sessions, and have a voice in planning. It builds confidence of members

to speak publically and assert their views

It creates a platform for advocacy and change, and develops local leadership and governance.

It leads to sustained behavioral change and positive action on a wide range of health, hygiene,

nutrition and livelihoods issues.

Membership is encouraged through positive peer pressure, the wish to learn and achieve the wish

to improve personal/family/community health, the sense of belonging and recognition. The club

savings and loans function can also promote membership

Positive household and community action is created by positive peer pressure, pride, recognition,

education, ability to pay (by the saving and loans scheme), competition between households etc.

Key Principles of Community Health Clubs

Community Health Clubs are established by, and owned by the communities. Below is a list of some of

the important principles for the clubs, which should always be considered by members, facilitators

(CHWs), and also supporting personnel (GOAL, DHMT, CHO, Peer Supervisors etc). These principles should

be agreed by all those in the clubs, plus other important community members (such as local leaders) and

the previously mentioned support personnel.

a) The clubs are initiated by communities, for the benefit of the community. External support needs

to be very careful not to negatively affect this community ownership by prescribing things to the

clubs (like size, membership, committee membership etc), nor expecting accountability of the

clubs externally (e.g. to Goal). These are community clubs, not GOAL clubs.

b) The decision to take household or community action should be based on club decision and/or self-

realization, rather than being ‘told’ to do it by the CHW, CHO, GOAL or other external personnel

c) Membership of the clubs should be open to all who wish to join, regardless of gender, age,

income, religion, education or any other personal circumstance

d) Clubs are non-political, and are not to be used to promote any individual’s personal gain

e) Participation in the club savings and loans scheme is voluntary (possibly with the exception of

social fund contributions), and should not prevent some poorer households from participation.

Members are at liberty to decide themselves what they wish to take loans for, which can be

advised but not controlled

f) In the club, all members are equal, all have valid views and contributions, and should be

encouraged to participate. No individuals should dominate. Women and men have the same

status in the club. Those in positions of power or elevated social status that are in the club, are

equal to all other members in the context of the club

g) There should be no payment required to be a member of the club, or to receive the club sessions

delivered by the CHW

h) Sessions should be enjoyable, participatory, and based on self-realization, rather than teacher-

student ‘sensitization’. Members should be encouraged to question, contribute and learn, and

there is no such thing as a ‘stupid’ question or ‘stupid’ answer.

i) Club meeting times should be agreed by all members and based on when people have available

time (not necessarily the most convenient time for external support personnel), and ideally not

take members away from livelihoods activities.

j) Strict timekeeping is essential. Members, CHWs and external support personnel should all respect

everyone’s time as valuable, and not to be wasted

How to Use this Manual, and Run Participatory and Fun

Sessions How to use this kit

Please read through these notes before you begin to work with the manual and flash cards – they will help

you to navigate your way through the toolkit.

Written activities

Activities in this kit do not assume that participants are literate. Sessions are either based on oral or visual

teaching aids. Oral procedures build on the local culture of story-telling, songs, drama and role plays.

Flash cards

Some flash cards are illustrations that are specially adapted to local cultures and practices. Other flash

cards are photos taken in Koinadugu District, Sierra Leone (by CARE SL), others by the author of this

document, and some taken from interet and SMAC resources. Wherever possible you should complement

the materials with real objects found locally, and with demonstration items provided.

Time

Each session has been designed to take approximately 1 hour to implement. If there are many people

present and if they are all very involved and want to discuss a lot, the session will take longer.

Space

Try and ensure that your space is not in the path of a major thorough-fare. Arrange seating in a semicircle

or circle as this allows people to see and hear each other. Some activities and energizing games need

space to move – make sure you plan for this.

Design of sessions

1. Each session should begin with a review of the previous session. This review serves a number of

functions: it can be used to re-enforce ideas and information. It also allows participants to check their own

learning, and to practice teaching others as they collectively review the knowledge gained previously. Use

the ‘key messages’ to help you highlight and summarize the main points.

2. After the review introduce the focus of the session for the day. Outline the purposes as these tell

participants what to expect.

3. Activities usually include the following steps: they start with participants’ knowledge and experience,

add new information and knowledge, and end with plans for how to practice new skills or apply new

knowledge.

Outline of sessions

We have attempted to create a layout that makes it easier to scan the materials:

Purpose statements give a clear indication of what the session is about and hopes to achieve.

Materials list what kind of resources and tools are needed to run the session. Please note that some

activities assume copies of visual materials for all participants. Photocopy or trace pictures if you need

multiple copies!

Procedure indicates the beginning of learning / teaching activities.

Notes contain messages to you, the field agent / facilitator.

Ask indicates questions to pose either as a way of beginning discussions, to analyze points made, or

to follow up on information. This toolkit emphasizes communication. Therefore, questions are not so

much a means of eliciting ‘correct’ responses but are an important tool for getting participants to talk

and exchange information, experiences and views.

Explain that introduces observations, comments, and explanations. Often these include possible

answers to questions asked.

Text in boxes contains possible answers to questions – probe for these. Sometimes this text will be

generated by the participants themselves – use the points in the boxes as a quick reference to check

whether all the main points have been covered. Do not repeat what has already been said but ensure

the information has been conveyed to all participants.

Highlighted text contains brief information that should be conveyed.

Key messages summarize the main points of the session. Ask participants what the key messages are

– this will serve as a good indication of what has been learnt. Alternatively, outline the key messages

yourself.

Action outlines suggestions for follow-up activities. Participants plan how to put into practice what

they have learnt. Sometimes these actions have to be undertaken individually, at the household level.

At other times they are done collectively. Encourage participants to make their own suggestions for

actions or follow the suggestions made here.

Preparation

Each session needs to be prepared thoroughly and carefully: read through the whole activity and ensure

you are clear about the procedure. Some of these activities are not easy processes. Take time to think

through it so you feel at ease during the session. Visualize what might happen: anticipate what responses

you may get and imagine how you will react to them. Check your own understanding of particular diseases

or conditions and discuss them with a colleague, if necessary.

Participation

Find ways of including all members of a health club. Often, the same people give responses or volunteer

for action. Those whose voices are loudest are not always the most productive and insightful participants.

Remember that we are socialized into speaking up or remaining silent: create space for those who seem

more reluctant. Let their voices be heard. This will affect women and youth, in particular.

Flexibility and creativity

Be sensitive and responsive to local needs and moods. Use your imagination! If you feel shy about a new

activity ask participants if they are willing to try something new with you. Thank them for ‘taking a risk’!

Be prepared to laugh together – laughter is a great way to break tension and build a sense of unity in the

experience.

Energisers

At the end of this kit you will find a range of ‘energising’ games. Use them to suit your needs: to divide

the large group into smaller groups, to break tension, to relax participants, or just to have fun. Ask

participants to invent their own games.

Demonstration Items

The delivery of many of the sessions requires demonstration items, not only the flash cards. In the GOAL

pilot project, some items were provided to the CHWs as a demonstration kit, and other materials are

sourced locally by the CHW/CH Club committee.

Product demonstrations and visits from local suppliers

For many of the topics, particularly relating to hygiene and sanitation, there is

the opportunity to demonstrate and promote locally available products, and

discuss how to improve access to these products in the communities. This could

include showing the different food and water storage containers available,

personal hygiene products, local and imported soap, rat traps, sanitation

products etc. The club savings and loans mechanism helps build the member’s

ability to pay for such products, so the clubs can be used where appropriate for

local suppliers (e.g. hawkers) and artisans to visit, explain and demonstrate

their products to the members. This should be only for products relevant to the sessions.

Existing/commonly used items in the community can be taken from some houses and compared to the

‘improved’ products that are on the market.

Innovative ways to communicate the messages

On average, people remember much more what they do (e.g. participatory demonstration), and what

they see (e.g demonstration items, role plays etc, and what they sing, than what they simply sit and listen

to.

Be creative in ways to communicate messages and concepts, avoiding reading out loud or ‘telling people

what they should know’. This could include:

Inventing songs about topics

Role play and drama skits

Community walks, visits to member’s homesteads to show existing practices

Using locally available materials to demonstrate concepts

Make up stories that convey the message

Quizzes and competitions, question and answer

Use flip charts

Other Key Aspects

Keep topics simple and not too dense – allow plenty of time for discussion/question and answers.

Prioritize the most important messages (e.g. hand washing at key times with soap more important

than exact 10-steps method to wash the hands). Get the participants to recap the key messages

at the end of the session and beginning of the next session

Identify what ‘actions’ or homework should be done before the next session (e.g. construct tippy

tap etc), and review in the next session who has done/not done, and discuss why, and ways to

overcome this challenge.

How to Establish & Manage the Clubs

Roles & Responsibilities The following key persons are expected to be involved in the pilot of the community health clubs at

community and chiefdom level:

Person Role/ Responsibility

Community Health Worker

In addition to their day-to-day responsibilities as a CHW, to establish the clubs, facilitate the sessions, follow-up on homework/actions of the clubs through the club management committee, collect/review/transmit club reporting, sign membership cards.

Club Members Attend and actively participate in the sessions, undertake the agreed actions / assignments, report on their individual progress, participate in community decisions and community action, cascade information to other members of the household.

Club Management Committee

Transparently and accountably administer the club savings and loans component (although additional members could also do this), assist the CHW to deliver sessions (such as drama skits, role plays, demonstrations etc), follow-up individual household assignments, organize and oversee club-agreed community actions, monitor and report on club attendance and progress.

Peer Supervisors, Chiefdom Health Overseers

Provide support, guidance, mentoring and monitoring to the CHW for their work with the clubs. Where necessary, to co-facilitate some topics. To confirm, collate and consolidate club monitoring information for their catchment areas.

PHU Staff To participate in monthly review sessions, provide support to CHWs/Peer Supervisors, and report back to CHWs/Peer Supervisors on health issues and trends in the PHU catchment population.

To be updated if other community engagement structures are added in future, such as the VDCs.

Establishing the Clubs

Introduction Meetings

In order to promote a local sense of ownership of the club as a home grown CBO, the Community Health

Club needs to be carefully introduced into an area in the preliminary stages to avoid political suspicion.

This is usually done by the community health workers in consultation with the ministry of health and local

leadership (Councilors, politicians, village elders, religious leaders and headmasters, CHO) to explain the

idea so that the officials are well acquainted with it before the public are involved. The local leaders

together with the CHWs then call a public meeting and introduce the idea. Alternatively a chiefdom level

meeting with the key stakeholders can be held presented by the DHMT/Kenema District Council. For both

of these meetings, GOAL should take a back seat, with minimal visibility, to avoid people perceiving this is

an ‘NGO’ initiative, and raising expectations. It may be relevant for GOAL to be absent from the community

level meetings. The programme is outlined and those interested are invited to meet and register as

members of the health club on voluntary basis. The principles and the purpose of the clubs as mentioned

in the earlier sections of this document can be explained in this meeting.

Separately and additionally, a 1-day orientation training should be given to the staff at the local Peripheral

Health Unit on the CH Club approach, and how they may be involved in the process.

Session 1 - Community Mobilization and Discussing the Establishment of the Club

Following the formal introduction, the CHW (likely together with the Peer Supervisor for support)

undertakes the initial participatory mobilisation sessions. The purpose of these sessions is to mobilise the

community to realise themselves the health and hygiene issues in their community, and how education

and community action through a club can benefit the whole community.

At the end of the session, a discussion should be held to consider the idea of establishing a CH Club, what

it’s main purpose would be, and how it could be run. The community would (hopefully) agree that in the

next session, the ground rules of the club would be agreed, and potentially the management committee

elected (if appropriate at this early stage). If the community is large, there should be discussion on

establishing multiple clubs, and how this could be done.

The session plan for this initial mobilization session is covered in Section 2 of this manual.

Session 2- Defining the Club Purpose, Agreeing Ground Rules, Building

Communication Skills

The second session should be focused on defining expectations for the club, establishing agreed ground

rules for the club and sessions, and potentially discussing around electing the club management

committee (if appropriate at this early stage). If the larger communities are not already split into a series

of smaller groups/potential clubs, this issue should also be discussed. The concept of the club savings and

loans scheme can also be discussed (if appropriate at this early stage).

The communication skills topic will be covered within this session. The session plan for this session is

covered in Section 2 of this manual.

Establishment of the Club Committee

The club management committee’s role is defined in the earlier section of this manual. The community

members should be given the space to define their committee members and composition. Guidance

rather than standards can be provided to the community members. Ideally the committees would not be

overly large (as the clubs themselves are small). Key positions could potentially include a

chairman/chairlady, a secretary (must be literate) and CHW could be an Adviser but potentially not

member of the committee. The CHW could however be a member of the CSL. Composition does not have

to include community members that have been on previous WASH or Health initiatives (such as natural

leaders, WASH Management Team etc), and participation in the committee is entirely voluntary, with no

cash or in-kind benefits. Meaningful representation of women on the committee is very important. It does

not have to include influential persons or local leaders, particularly as there is supposed to be minimal

power dynamics brought into the clubs. Election would ideally be made by the club members, and based

on those who are highly active at driving positive change in their community, rather than for reasons of

popularity or seniority. Clubs may decide to replace or re-elect for positions if committee members are

not performing their functions.

Membership Cards

Each member is issued with a membership card that outlines the content

of the Phase 1 topics. This card is a form of social contract between the

community and the CHW who facilitates the clubs. At the end of each

session the CHW signs the members’ card, and the club committee signs

the CHW’s card. In this way they signal shared responsibility, transparency

and accountability. The members can see their own progress as more of

the sessions are signed off, as they work towards graduation.

Competitions and Exchange Visits

In addition to the standard sessions, the CHWs and committees may decide to undertake additional

activities as a club or committee. These may include:

End of module quizzes with prizes/ awards / public recognition

Inter-household competitions for the cleanest homesteads and most progress made (such as

the healthy home competition)

Inter-club competitions (particularly in larger communities with multiple clubs) on healthy

homes and progress made

Inter-club exchange visits to review their progress and share ideas

Competitions and ceremonies for achieving open defecation free status in the community, and

creating competiton among communities, sections and even chiefdoms for ODF progress

Graduation

Once the club has gone through the full Phase 1 syllabus, there will be a formal, public graduation

ceremony, whereby each graduating member is provided with a quality, framed certificate. This should

include bringing in local leadership or dignitaries where appropriate, and to reinforce and acknowledge

the club and members own sense of pride and achievement.

Club Savings & Loans (CSL) Scheme

To encourage membership, and build the individual member and overall club

financial capacity to (potentially but not exclusively) finance actions relating to

health and hygiene, the clubs will include a Club Savings and Loans (CSL)

function. This is open to any member of the club that is regularly attending

sessions, and not likely to be open for non-members, to encourage

membership. The CLS would require meetings every week for members and

the committee to administer the scheme, which means there is a good opportunity to combine the CHW

sessions with the CSL meetings. The CSL meeting could be undertaken at the end of the CHW session. If it

were done during the session it would likely be disruptive, and before may mean members leave before

the end of the session.

A subsequent training and manual will be provided to the clubs for the CSL component.

Sanitation Activities

Achieving total sanitation is a major aim of Phase 1. This means that all people use toilets, and all the kaka

of young children/babies is disposed of in the toilets. This manual provides guidance on minimal features

of the toilet to ensure it is hygienic (a stable squatting platform, a cover over the squat hole, and a

handwashing facility). It also provides guidance on ‘cat sanitation’ practices (burying shit) for when people

are out of the village on patrol or at the farm.

The approach to sanitation is involves: mobilizing the whole community against open defecation; helping

the community make and follow-up a sanitation plan to achieve total sanitation; providing some basic

education on how to construct a hygienic toilet; helping communities to save for/make deposits for toilet

products; training local artisans to produce improved toilet products; helping the artisans to market their

products and services to the community health club members.

A major finding of GOAL’s earlier pilot on rural sanitation marketing was the need for bulk orders from

the community. It is difficult and expensive to get materials transported and masons to come to the

villages to construct for only one or two slabs. However if the community members come together and

combine their orders, it makes the transport costs cheaper, and masons more willing to come to the

village to produce the products on site. Production of concrete products off site and transporting them to

the village is not an ideal option. This pilot, during the ‘planning for total sanitation’ session, helps

communities to think how they can combine their orders and deposits for products. Some clubs may end

up using the CSL cash boxes as a kind of savings deposit box for the sanitation orders.

Different households will have different preferences on product, and some will be ready to reach the full

savings amount quicker than others. It is therefore reccomended that each member saves as much as

they want for their individual order. It may not be a good option to have communities (rather than

individual members) saving based on a fixed amount per member that goes into a common savings fund.

Monitoring, Managing of Clubs, and Reporting

The day-to-day running of the clubs will be the responsibility of the club management committee with

inputs from the CHW. The committee would keep records of attendance at each session in a provided

ledger. This information can be provided to CHWs, Peer Supervisors/CHO and GOAL personnel when

needed. The committees would also potentially administer any prizes, funds or other assets that are

provided to or generated by the clubs. The management of the CSL will be covered in a separate manual.

The clubs (led by the CHW and committee) will undertake a participatory self-monitoring exercise (the

household checklist) early in the formation of the club (potentially in between session 2 and 3), and then

again at key stages of the syllabus (e.g. at the end of modules, and on graduation). The initial survey will

form the baseline information on which the extent of the challenge/targets faced by the club is defined,

and progress on improvements is monitored. This monitoring will be basic for the level of literacy of the

communities, and focusing on presence/absence indicators of key health, hygiene and sanitation (e.g. use

of hygienic toilet, covered water container, hand washing facility etc). This survey covers all member

households. The committee and CHW will be supported where necessary to consolidate this information,

and will report overall findings to the club members at the following session. This information would also

be provided to the CHW and onto the Peer Supervisor (and copied by GOAL) for monitoring. GOAL will

provide standard forms and trainings for the committee members on this.

The PHUs and Peer Supervisors would cascade information on health trends in the catchment to the CHW,

and the CHW would where appropriate provide information on total disease cases etc to the clubs (being

careful to protect patient confidentiality). This is aiming to increase the amount of information the club

members have regarding their progress, and building up the two-way reporting and accountability system

between the clubs, CHWs and PHUs.

Section: 2 Plans for Individual Sessions for Phase 1

Module 1. Mobilization and Forming the Clubs

Session 1: Community Mobilization & Problem Definition

This session could be for the whole community.

Purpose:

The purpose of this session is to mobilize the community to realize by themselves the health and

hygiene issues in their community, and how education and community action through a club can

benefit the whole community.

Outcome – people interested in the club, and how it could be run (provisional discussions)

To start to discuss ground rules of the club.

Materials

Vanguard

Markers

Procedure

Ask : What are the common diseases that affect you in your community? List down the diseases

Ask Volunteers to represent one disease each that they identify, and stand up. Each of the volunteers can

be named Mr or Mrs (name of disease).

For example, Volunteer 1: I am Mr. Malaria member of the Joru community,

Volunteer 2: I am Mr. Diarrhea member of the joru community

Ask them to introduce themselves to the audience as how they are labelled and act the disease they are

named.

Ask: is it good to have such diseases and health issues in our community

Ask: what do you think has made this diseases and health issues become our friend?

Ask: who owns this community

Ask: who has these problems in the community

Ask: who are these problems affecting?

Ask: problems that are yours and affect you, who will solve them? Outsiders or you the community

people?

Ask: Why are you solving this problem?

Ask: if you have realized the reason for solving your problem, for those reasons what can you do to make

this community be disease and health issue free?

Ask: in fighting to maintain good health in our community, is it one person’s business (or all the

community’s business)?

Ask: If we now know that it is everybody’s business, how can everybody be involved?

Explain that, everybody can be involved by taking note of the following

Facilitator’s hints

Forming of community health club to see community behavioral change with regard good health

and hygiene behavioral practice set is achieved

The community health club is a new approach

To be part of the community health club is voluntary, regardless, age, sex, religion, societal and

political background; it is purely willingness, no appointment.

To be a member of this club is free

The average membership of the club is 20 people, with one representative per household

This club can be form into more than one club depending on the number of households and size

(big) of the community.

The purpose of the club is to mobilise the community and build understanding on health and

hygiene issues, and build community action to remove disease from the community

The clubs meet each week and cover a different topic. They are given membership cards, and

those who complete the course graduate.

Action

Discuss as a community and in your households about joining the club. Attend next week’s session.

Session 2. Defining the Club Purpose, Agreeing Ground Rules, Building

Communication Skills

This could be for the whole community, or if already separated, for the individual clubs.

Purpose:

To give participants a better idea of what the community health club is about, and discuss some

expectations and possible ground rules

Encourage people’s interest to be members of the club, and discuss about it’s establishment and

executive committee

Learn communication skills on speaking and listening

Introduction:

Recap from the last session about the community wanting to address their own issues, and the interest in

forming a club.

Ask: Why do we need to establish a community health club?

Ask: Who own this club?

Ask: Who can be members of the club? (should be open to anyone interested to join. It should be people

who are active and want to make change in the community).

Ask: can anyone join? (Yes, anyone who is interested can join – it is voluntary to join).

Ask: who are interested to be members of this club? Explain that been a member of this club, you will be

provided with a membership card which details all the topics to be covered. Sessions are covered over 1-

1.5 hours at an agreed time every week. Once the sessions are completed (to be delivered by the CHW),

you will graduate and be given a certificate.

Ask – what is the purpose of the club?

Explain – the purpose of the health clubs are to give the members the skills and knowledge to drive

positive change in their households and community, to empower the members, and reduce diseases, and

improve the lives of the community.

Explain – we are now going to do a short session on communication skills.

Communication Skills

Purpose

To develop important communication skills as a basis for collective learning and teaching

To understand how real benefits from health club sessions depend on the respectful behavior of

all

To improve listening skills

To consider how an individual’s status and power affects participation in health club sessions (and

beyond)

Material

Flip chart

Marker

Procedure

1. Focus on ground rules

Explain that this health club course depends on all the members working and learning together.

This session will look at some of the important attitudes every member of the health club needs to develop

so that each person is able to communicate respectfully, productively and equally.

Ask: What are some of the rules we can agree on so that everyone feels free to participate in these

sessions, and everyone has the chance to learn and enjoy them? Collect suggestions; if necessary, probe

for some of these:

Suggestions for ground rules

Agree on a starting time and ensure punctuality settles down and do not interrupt the session by moving

in and out listen to each other attentively: do not interrupt! make space for others to speak: do not

dominate discussions by insisting to speak every time you want to take a risk: speak up and be heard do

not make comments that may make others feel bad (for example, comments that put women or young

people down) do not laugh at others as it may make them feel shy agree on actions to take after the

sessions and try your hardest to take them; for example get into habits of cleanliness and respect

Communication Skills

PLANNING TOOLS

2. Game: Passing on the message

Explain that it is important that we make informed decisions – that is decisions that are based on clear

and correct information.

Explain that the next activities are short games that aim to demonstrate the importance of clear

communication – both listening, and talking. Lean over to one of the participants and whisper a message

into her / his ear. The message should be a short sentence. Ask her/him to pass the message on by

whispering it into the next person’s ear, then ask her/him to pass it on – and so on. Each participant must

just pass on what s/he heard – even if it makes no sense. Bit by bit the message will become totally

garbled. Ask the last person what s/he heard.

Review the activity.

Explain that messages and information become distorted as they are passed on. Therefore, it is important

that we listen carefully and report accurately. It is also important to ask questions – if you have not heard

something clearly or understood something do not be afraid to ask for it to be repeated or explained.

3. Game: Giving instructions

Ask participants to work in pairs. Partner A will instruct partner B to put on a shoe. Explain that partner B

pretends s/he has never seen a shoe and does not know what it is. (They don’t even know which side is

up and which is down, and which is the front and which the back). Partner B must do exactly what partner

A says! Unless partner A gives very clear instructions, partner B will get very confused and there will be

much laughter as s/he gets it wrong!

Swap over: partner B will instruct partner A to put on a head scarf (or something similar).

Review the activity.

Ask: Did people find it easy to give clear instructions? What was it like to receive instructions that were

not clear? What were the frustrations for both partners?

Discuss how we make assumptions about people and actions such as simple tasks. When things go wrong

we blame the other and call her/ him names (like “stupid”). However, often the message is not clear and

we need to blame ourselves rather than the other for getting it wrong.

Explain that collective decision-making requires that all partners come to see and understand things the

same way. This can only happen if we all both speak and listen carefully.

4. Exercise: Peer listening

Ask participants to work in pairs and sit facing each other. Ask each pair to decide who will be the speaker,

and who the listener. Speakers now have 2 minutes to talk to listeners about their hopes for the future!

Listeners must not interrupt. After 2 minutes call ‘stop’. Ask the listeners to tell their speakers what they

had said!

Ask speakers: Did you get an accurate reflection of what you said? (Yes or no?)

Swap over: speakers are now listeners and the new speakers will tell them what they hope for the future.

Again ask: Did you get an accurate report of what you said?.

Ask: Did any of the listeners find it hard to listen and be attentive during the conversation?

Why?

Collect responses; if necessary, probe for some of these:

Obstacles to listening

while one person speaks, we begin to think of what we will respond to her/him, instead of hearing what

the other says when the other says something that we do not agree with or dislike, we begin to switch off

and stop listening when someone speaks for too long, or uses words that we cannot understand, we

switch off and stop listening while the other speaks, our minds wander and we begin to think of other

things (for example, having to go to the fields to work, or what we will do about the sick child) our own

lives feel more important than someone else’s

Listening

Tell a little story about listening and not listening. Act out the story as you tell it. Use this example or make

up your own. When I was a girl and my mother spoke to me and told me to do things, I often forgot what

she said. I saw my father and brother doing the same thing. She got upset and angry with us and said we

treated her like a child. But when my father said something, we all listened and never forgot what he

asked us. Then I watched him with my grandmother or the teacher: when he listened to them, it was just

the same way we listened to him!

Ask: Do we listen to all people equally regardless of their social or economic status? What about the

husband, or father? What about the small children? What about the teacher, the shopkeeper, the chief?

Explain that listening attentively is linked to issues of power: those who are seen as important and

powerful get our attention more than those who have less power or position.

Ask: Who has the most power in this community, who has the least? What gives them the power? Collect

responses; if necessary, probe for some of these:

Sources of power

Information: someone who possesses or has access to information is perceived as important

Connection; someone who is well connected to leaders and knows people who are influential is perceived

as important expertise: someone who is recognized as having particular skills, understanding and insight

is perceived as important position: someone who has status and is perceived as being in the position to

influence others and decision making processes is perceived as important – position is very much linked

to gender and age.

Personality: someone who is a forceful person and is well-liked and admired by others is perceived as

important

ASK: How should people who are perceived as (more) important use their power in the health club?

Suggest that all those who have status, or information, or a forceful personality use this power to

encourage others to speak up rather than put themselves forward.

Key messages:

Working together requires us to listen well and be clear when we speak.

Listening is hard work: it means having an open ear to others instead of hearing mainly our own

voice.

Communication is a give and take: both sides have to make an effort for it to succeed.

There are different sources of power – it is useful to work out who has power and where it comes

from, if you want to change relations amongst the more and less powerful in a community.

Now returning to the establishment of the club:

Ask – them to break into small groups, and brainstorm on possible ground rules that would be important

for the club?

After a few minutes ask the groups to present, and discuss. Participants to comment and come out with

key important items from each presentation and noted down

If not already raised, ask the following:

Ask – can anyone can join, regardless of age, sex, religion, tribe, income etc?

Ask – in the club, is everyone considered equal? Even men and women? What about rich and poor

people? In the club, how can we remove status during the sessions?

Ask – can one person dominate the discussions or tell others to shut up?

Ask – is time keeping important? What happens if the CHW or a member is late?

Copy agreed ground rules to be used for every club session.

Explain – the clubs are normally around 20 members to keep group sizes small so everyone can actively

participate. Ask – does the club need a small committee to help the CHW?

Explain that the committee would assist in the organizing of the club meetings and activities, and help on

follow-up of agreed actions.

Ask – what positions would be necessary (suggest to keep sizes small – e.g. just chairman/chairwoman,

secretary, PRO and treasurer). Discuss how and when these people could be elected, the main criteria for

selection etc.

Action:

Practice listening in your home: repeat to yourself what the other has said, before responding

Enroll members for the club and consider voting on the committee

Module 2. Basic Health Understanding, Monitoring, & Health

Seeking Behaviours

Session 3: Problem definition on health issues, health club reporting and health

monitoring in the community Purpose

To identify common diseases afflicting members of the health club.

To introduce a tool that helps health club members to monitor health and disease in their community

To begin to develop understanding of the use and usefulness of health and disease monitoring

To introduce community monitoring as a collective planning tool

Materials

Charcoal or a stick for drawing on the ground

Small stones (collected locally)

Examples of monthly health monitoring forms of the CHW (if appropriate)

Examples of club baseline monitoring checklists

Flashcards for the health monitoring chart (see below)

Session activities

Introduction

Welcome participants and ask them: How are you? If they say ‘fine’, ask them to describe signs of being ‘fine’.

ASK: How do we recognize a healthy person?

ASK: What do you do to keep healthy?

Take a few examples and point out that the wellbeing of our bodies is closely linked to the wellbeing of the environment.

EXPLAIN THAT the health club course is about improving the health of the community. To do this, it is important to know how sickness and diseases affect the community at that moment. Explain the importance of having an ongoing record of the community’s health as this helps participants to decide in what ways it can be improved.

Community Health club reporting

ASK: What kinds of health problems do your babies and small children have most often? What about the older children? What about older people? What about you, yourselves?

ASK: Which of these diseases do people die from?

Explain that the CHW is responsible to collect information on the number of births, deaths, and common health issues.

ASK: What health problems do we have in the community?

Responses should include:

malaria

diarrhea

acute respiratory infections (ARI)

skin diseases

worms

Health monitoring chart/community information board

Hold up the Malaria flash card. Ask – what is this? Get everyone to agree it represents Malaria. Put it on the ground.

Do the same for diarrhea, worms, pneumonia, skin diseases. Lay each out underneath the other. Take charcoal and draw a table round the cards, as indicated in the black lines in the table to the right.

Ask – did anyone from your household suffer from any of these illnesses over the last month?

Show the community a pile of small stones laid next to the table. Explain that each member should put a stone for any incidence of that disease that occurred to their household in the month. For example, if one household had two pikins with diarrhea last month, they should put two stones in the diarrhea box. See the example table above – the blue circles are the stones.

To avoid embarrassment of everyone watching the member showing the diseases in their household, then all members get on their feet, and start singing together in a circle. One at a time the member leaves the circle to put the stones on the chart. Once every member has laid stones, everyone sits back down and looks at the chart.

ASK: Which pile of sticks / stones is the biggest? So which sickness has been the biggest problem, recently?

ASK: Has this problem been bad for all the members of a family? Why has this household been so badly affected? Have some members of a household been worse affected than others?

EXPLAIN THAT if we want to better understand health and sickness, we need information. For example, if we want to learn about diarrhea, we will look at who has had it, and how often, and how they live, and then we can plan actions to stop this from happening. We know that small children have diarrhea more often than older people. But do they also suffer from malaria more than the older people do? What about ARI?

Suggest a change to the chart. Remove all the stones from the table, and ask people to put stones only for the under 5 years children in their household. Repeat the song and continue until every member (who has children under 5) has finished. Review the piles and discuss.

ASK: What do the different sized piles of sticks /stones on the chart mean? Are some members of households more vulnerable to certain diseases than others? Why do you think this is so? What can we do about it?

EXPLAIN THAT this information allows HEALTH CLUB members to record and then analyze what has been happening in their community in terms of health over time. When they look at the chart they will ask questions such as:

Were there older people suffering from ARI at certain times, and why?

Were there more children with diarrhea in a particular week? Why was this the case?

Were there times when very few people had malaria? What was happening at that time? What was different?

EXPLAIN THAT this health monitoring chart will allow the HEALTH CLUB members to better understand how their actions affect health and what changes they can make to improve the health of the community

Explain that the CHW is responsible for collecting health information monthly. Information on number of cases (WITHOUT NAMES) could be reported to the club each month by the CHW. Explain this is only for those who report to the CHW, as those going to quacks and traditional healers are not reported.

ASK: As a club, do we want to know that information? If so, where shall we display it? Is there any groundrules on this (e.g. patient confidentiality etc)? What other information would we want on there?

Where could we as a club display this information that is collected by the CHW monthly? They hang it publically at the PHUs. Do we want the information in the community? If so, where? Discuss the idea about establishing a information board for the club to present this information, and also other relevant club information. The information could also be provided to the members verbally each month by the CHW.

ASK: As a club, do we also want to know what the extent of our hygiene problems in our community, and track our progress in addressing these problems?

EXPLAIN: the club could do a baseline survey to see how hygienic the community is, taking an inventory of all member households, to see how healthy they are, and to put this info on the board (total numbers, not reporting whose household it is (ANOMONOUS). This survey could be done again after some of the sessions to see the progress the club is making.

ASK: Is this something that the club thinks would be useful?

Show the checklist below, and ask if this would be useful to do for the members? Why? Who could do it? (normally done by the club committee, and results reported at the next meeting). It is important the names of households are kept anonymous.

Facilitator’s hint

Key messages

Collecting information about diseases helps us to understand the health status of our community. You should report all cases to the CHW for monitoring and possible treatment / referral

Keeping regular records is one way of knowing what diseases are worst in our families and communities, and who is most and most often affected. However keeping information anonymous is very important

Analyzing those records helps us to understand what we are doing right, and what needs improvement.

Disease monitoring helps us to make decisions for the future, collectively. Such decisions include asking for more support from the health centers (PHUs) to prevent outbreaks of certain disease

Tracking of club progress will help to mobilize the community by showing the extent of problems in their community, and can be motivating to track progress made

Action:

Club identify a place for the health information and other CH Club info can be displayed publically, and construct the board before the next session

CHW puts up non-sensitive information on the board in terms of disease incidence through time in the community

The club committee organize the club member baseline survey to undertake before the next meeting and report back to the club on the results (not mentioning names of the household).

Household Inventory Checklist Example:

Does the Household Have: Example house hold

House hold 1

2 3 4 5 6 7 8 9 10 Total

Tippy tap with water and soap/ash available at the kitchen

Pot rack

Storage container covered and raised from the floor, with long handled bailer. OR use narrow neck container with lid to pour, OR use veronica bucket.

Toilet with lid to prevent flies

Tippy tap with water and soap/ash available at the toilet

Clothes line

All children <5 and pregnant women sleeping under bed net

Other items could be added, such as rodent proof domestic refuse container, food storage container..

Session 4: Body Mapping, Germ Theory & Transmission

Purpose

To introduce an understanding of what the body looks like inside

To identify different parts of the body responsible for different functions

To begin to make a link between different parts of the body and signs and symptoms of disease

To understand how germs are transmitted from person to person

Materials Needed

A broad plank or something that is big enough for a child to lie on

Large Vanguard

Markers

Chalk or charcoal

Flash cards germ theory (see below)

Session Activities

1. Introduction: role-play on health and sickness

ROLE- PLAY 1: Ask for 2 volunteers. Tell one: imagine you are feeling very healthy and well; tell the other: Imagine you are feeling sick. Tell both; meet and have a conversation about how you are! Allow the conversation to go on for a few minutes only. Thank the volunteers

ASK: What did the person in the role-play say that made you think he/she was very healthy and well?

Collect signs of wellbeing.

And the other that made you think he/she is feeling sick?

Collect signs of sickness.

Expect responses such as the following:

Wellness Sickness

Happy unhappy

Full of energy Tired; no energy

Big appetite No desire to eat

Shiny skin, eyes and hair Dullness in looks

strong Fever, pain, specific symptoms

ASK: What are symptoms of sickness where we feel ill but there are no physical signs on the body?

An example may be ‘tiredness’.

ASK: What goes on in the body that could make somebody tired?

Tiredness may point to anemia, worm infestation, and emotional stress, mental distress etc the list should include mental illness such as depression or dementia, being ‘bewitched’, HIV/AIDS, and unexplained diseases.

NOTE:

If someone mentions ‘juju’ or witchcraft, explain that a person can become ill if she/he really believes strongly that someone is trying to harm her/him. However, someone who believes s/he is bewitched or has had a spell put on her/him (juju) is really the victim of her/his own fears.

EXPLAIN THAT it is impossible to bewitch a person who does not believe in witch craft

Exercise 2: Ask a volunteer to lie on a vanguard lied on a table or board. The volunteer should lie on their back, with their face pointing to the side (to allow tracing the nose and mouth).

Draw round the edge of the torso and head, as with the picture to the right. Ask the person to get up.

Hold the flashcard to the right up. Ask the participants to identify each item (lungs, gut, stomach etc). Help them by explaining what happens when you breathe in and out (it is your lungs rising and falling) When you have diarrhea it hurts in your belly. This is your stomach and guts. Show the throat and explain water/food, and air go down different pipes – food and water to the stomach, air to the lungs.

Ask a volunteer to carefully draw the detail of the lungs, stomach etc on the vanguard with the person’s outline.

ASK: How does the diarrhea enter the gut?

Ask: why and how is it useful to know what our bodies look like inside?

The essence of the above role-play is to demonstrate what is in the community. Strangers would not understand the community because they would be outside and not know what it looks like inside. In the same way, we know what our bodies look like on the outside, but we don’t know about the inside.

EXPLAIN THAT signs and symptoms on our bodies are helpful when we try and work out what is wrong with us. However, we also need to look at the inside and test body-fluids such as blood or urine in order to really know what is wrong, and to give the right medication. Explain that it is therefore important to go to the health center and have tests done, if we are unsure what is wrong with us.

Ask – can a quack test? Can a dispenser test? Can a traditional healer test?

Key messages

Working for health begins with listening to our own bodies: our bodies tell us when something is wrong, and if we listen well and identify the signs, it helps us to make a decision on how to act.

If we want to understand serious diseases, it helps to know how the body looks inside, and how different parts of the body are connected and, therefore, how infections spread and travel from one place to another.

The respiratory system consists of nose, windpipe and lungs; the digestive system includes the mouth, gullet, stomach and gut.

3. Demonstration of germ theory

ASK how the sickness from one person can get into the other person, using the body map as a guide.

ASK how can someone with a chest infection infect someone else?

EXPLAIN – through coughing, with someone else inhales the sickness and it enters the lungs. Explain it is important to cover your mouth when you cough, and wash your hands. Explain it is risky being in a poorly ventilated place with someone with a chest infection.

ASK – how can diarrhea sickness get into the gut? Prompt different ideas around dirty hands, dirty food, dirty water etc getting into the mouth and then going into the gut

Role play

Myth/ misconception on Health related issues

I dreamt giving a food in my sleep make me sick that is his belief

Role play on the above myth

Ask four participants to come up

Person1: play the role of a sick person vomiting

Person 2: Play a role of a herbalist went to for treatment but the sick person problem was not solve

Person3: play a role as an adviser, advising for the sick man to go to the health Centre to find out the cause of the illness

Person 4: play a role of a nurse who diagnoses the patient and proved him malaria infected was treated and get better.

Hold up the first germ theory card, and ask someone to explain what it shows. Ask them to stand up and hold the card at their chest. Do the next one, and next one etc (as the cards show below). Ask the volunteers to stand in the line as below.

Ask the audience to discuss what they think happened (dirty uncovered drinking water container. Person drinking from the storage container with dirty hands. He drinks dirty water, and gets diarrhea.

Repeat the same process for the next set of flash cards:

Ask what happened (mother washing a child’s kaka, cooking with dirty hands, their babies crawling with their hands in dirty environment, family eating together from the same bowl with their unwashed hands, everyone gets diarrhea).

ASK: What is the lesson learnt from this

Explain the following:

Germs are passed on from one person to another. If one person has diarrhea, he/she can passed it to another person. If someone has disease on their fingers and prepares food, they may make the food dirty. If someone puts dirty fingers in their mouth, it can make them sick. If someone drinks dirty water, it goes into their stomach and makes them sick.

ASK: What actions can you do to keep you and your children safe from these diseases?

Expect answers on – handwashing with soap, keeping the compound clean, drinking and storing safe water, using a toilet, washing food before eating etc.

ACTION:

Members go and explain what they learned to their families and children

Help their children draw body map on the ground

Put up the club body map on the club information board to be used in future sessions

Participants make up songs about how diseases enter into the body and how these can be prevented

Session 5: Health Seeking Behaviors This section could be co-delivered or fully delivered by a visiting PHU staff member.

Session objectives

To know why people are not making use of the health facilities

To see how the PHU staff can build trust in the community in order to see the need and have high demand for PHU Services

To know the importance of reporting diseases and need for reporting early to the health Centre

To discuss traditional beliefs about witch craft, traditional healers and also using quacks/self-diagnosing

Materials

Flash cards (as shown below)

A PHU representative, possibly with some fake out of date drugs, and some real drugs

Session activities

1. Introduction

Before you start, sit with the health club committee members to prepare the following drama skit:

Person 1 is the traditional healer. Person 2 is the quack. Person 3 is the Nurse at the PHU, Person 4 is the CHW, Person 5 is the sick person.

The sick person goes to the traditional healer. He takes his medicine. After 1 week he is still not better (he is worse), he goes back to the traditional healer. The traditional healer advises him to go to the quack. After 1 week, he goes back to the quack, still not healed (even worse). The quack says go to the CHW. The CHW gives some basic treatment and refers him directly to the nurse at the PHU. The Nurse immediately checks him, diagnoses him and gives him drugs. Now he is better.

ASK – when we get sick, what do we do? Go to the CHW? Go to the PHU? Go to the Traditional Healer? Go to the quack/buy medicine you think is correct? Why?

Ask people to divide into groups and discuss, and then present findings. Discuss reasons why people prefer to go to different services, and do not judge or tell them they are ‘wrong’

ASK – who do you ask for advice if you feel ill? Discuss

ASK – Do any of you know what the job of the CHW is?

EXPLAIN – the main job of the CHW. Explain that they are formal volunteers of the Ministry of Health & Sanitation, and there are over 13,000 of them across the country, and have all been through standard training.

ASK – do some people choose not to use the services of the CHW? If not, why? Discuss. Do not try to force the services of the CHW on the club members.

ASK – what services are available at the PHU? Do you know where the nearest one is?

EXPLAIN – what the standard services and costs are of the PHU for visitors

Show the flash cards:

Ask – are these services available in other places? No? Best to go to the clinic.

ASK – do some people choose not to go to PHUs? Why? Discuss.

ASK – what are the risks of self-diagnosis / buying drugs from the market / from a quack?

Ask – do you have formal training in medicines? Does the quack? Does the CHW? Do the PHU staff?

EXPLAIN – there is a big problem in the country from fake or out of date drugs sold in markets or from quacks. These can do you serious harm.

ASK – If a stranger came to your community with a cup of liquid and asked you to drink it, would you do it? Would you drink a substance you don’t know what it is? Would you eat food that you don’t know what it is? How can you be sure the drugs are good for you?

Explain that drugs should only be prescribed by people who have training, otherwise it can do you a lot of harm. Explain the PHUS and CHWs get their drugs through government systems and they are regulated and not fake.

ASK – what are the advantages and risks of using traditional healers rather than government health services?

ASK – is there a problem if people try the traditional healer first and only go to the clinic when they are very very sick? Is this a problem?

EXPLAIN – delaying to seek medical attention can put you or your children’s life at risk. People who are sick should report to the CHW/PHU as soon as possible.

ASK – do you feel the PHU services are safe? If not, why? Discuss (and reassure concerns)

ASK – do you feel the PHU services are honest? Are they accountable to you? Do they tell you what your disease is and why you need the medicine? Do they charge for things that should be free?

ASK – how could the link between the Health Club and the PHU be strengthened? How can the CHW and the club help on disease monitoring and reporting?

Key Messages:

PHU and clinic services are safe

The clinics and PHU services should be accountable to the community, and in the case of health problems / immunization non-compliance etc, the community should provide information and support to the PHU/CHWs

The use of alternative practices and self-diagnosis may put you and your family at risk especially if it delays you seeking medical attention, however some traditional medicine can be effective

ACTION

Discuss what was talked about with family members

Module 3. Personal Hygiene & Health

Session 6: Handwashing Consider inviting a hawker that sells different types of soap (and other hygiene products) to attend the training and at an appropriate point allow them to show their products and explain why they are good.

Session Objectives

To understand how germs can be invisible, and can be passed from one person to another by hands, and can enter the mouth and make you sick

To understand how germs can get on the hands, and when to wash the hands

To understand the importance of hand washing with soap or ash not only water

To experience different types of soap

To understand how to construct a tippy tap

Materials

1 White/clear bowl of fresh clean water

Flash cards on germ theory (see below)

Palm oil

The body map drawn in the previous session

A Kettle or container for pouring water with water in it

A dirty hand towel

Different types of soap to be tested, including luxury soap and locally made soap, and ash

A constructed tippy tap, with a soap/ash holder, and covered out of sight by a lappa.

Session Activities

Introduction

Ask a volunteer to come up and pretend to have diarrhea.

Hold up the body map – ask them where it is hurting? (points to the stomach).

ASK – how can diseases enter the stomach from the mouth? Think back to the germ theory session. Ask how we get diarrhea?

Use flash cards to show how your hands can be dirty and how it can make you sick.

Ask – how can dirty hands make you sick? Prompt for answers on ways that dirty hands can contaminate – your food if you don’t wash before cooking? Your child if you don’t wash your hands

before feeding your child. Your mouth if you eat with dirty hands or put your hands in your mouth. Your water if you handle or take water from storage using dirty hands.

Ask – can germs be passed from one hand to another? How?

Ask – can you see the germs that make you sick?

Hand to Hand germ transmission

Ask a person to rub palm oil on his hand and shake the hands of another person and the other person do likewise with another person. Ask the following questions below:

What do you realize on your hand? Tell them it represents kaka.

How did it get there?

What could have prevented one person from not getting the hands of others like that?

How do you prevent the spread of germ from person to person?

Explain – germs are small – you cannot see them, but they can be passed from one hand to another.

Ask – did everyone wash their hands after they went to kaka today? Honestly? If not, is there a possibility some small bit of kaka could have been passed from their hand to yours?

Ask – how can you remove germs from your hands? Answer – handwashing.

Explain that cleanliness is very important to keep our bodies healthy and to prevent infection and the spreading of disease. Many common infections such as cold and a cough or diarrhea happen as a result of not enough cleanliness

ASK: Who is confident that he/she has a clean hand?

Ask a volunteer to come forward and wash his/her hands thoroughly in the white bowl of water with soap.

Invite all participants to inspect the water in the bowl

ASK: Is the water clean? Is the volunteers hands clean?

EXPLAIN THAT although hands may look clean, they are often not actually clean.

Effectiveness in dirt/germ removal and experiencing different types of soap

Ask four people to cover their hands in palm oil, and demonstrate the effectiveness of dirt/germ removal. Ask them to stand at the front and get them to demonstrate hand washing. Get the audience to count 8 seconds for each participant to wash their hands. Eight, seven, six, five, four, three, two, one!

Then review how much dirt is in the bowl/inspect how clean their hands are. Give:

Person 1: demonstrate the removal dirt/germ with water only

Person 2: demonstrate the removal of dirt/germ with ash

Person 3: demonstrate the removal of dirt/germ with local soap and water

Person 4: demonstrate the removal of dirt/germ with soap and water

Once each person has washed their hands, ask them to stand in the line facing the audience with their hands up. They are not allowed to wipe their hands.

Once they are all finished, ask the participants to come and inspect their hands closely. Ask the volunteers to call themselves mr water only, mr ash, mr local soap, mr soap. Ask – which one has the dirtiest hands?

Ask – who here washes their hands with water only? Is it effective?

Look at the ash, local soap and soap – all of them are effective at getting rid of germs, but water alone is not effective.

Ask – who here uses only water to wash their hands? Ask why they only use water?

When to WASH your hands?

Role Play/drama skit:

Perform a short skit with a helper, with the following story: You have diarrhea and defecate in the bush. You use a leaf and wipe your hands on a stick. Ask – are these hands clean? They then walk into town and meet people and shake hands, go and eat together with people, feed the baby, collect water with their hand from the water container in the house etc. Then show everyone sick with diarrhea.

Ask the mothers:

When you clean your child’s bottom with your hands, what happens when you then go and prepare food?”

Ask the rest of the community:

“What happens if you don’t wash your hands after going to the toilet, you shake hands with people and eat your food…”

Ask the imam:

“What happens if you don’t wash your hands before going to the mosque?”

Ask – what sicknesses do you think you can get from dirty hands? Answers include diarrhea, colds, Ebola, Lassa, worms, skin diseases.

Ask – when do you normally wash your hands?

Ask – when do you think it is important to wash your hands to protect you from diseases? When do you normally wash your hands?

Explain that you should wash your hands, WITH SOAP/ASH at the following key times:

After using the toilet

After handling faeces ( Such as cleaning a baby’s or child bottom)

Before eating

Before handling food

Before feeding a child

After working or playing with dirt

After tending or feeding animals

After sneezing(coughing) into your hands

Ask – if your neighbor does not wash his hands when he uses the toilet, is it a problem for you? Explain that by them not washing their hands after going to the toilet, it risks you and your family catching germs from them. Therefore you should encourage your neighbor to have AND USE a tippy tap.

Handwashing Facilities

Ask – what do you use to pour water to your hands when handwashing? Ask people to demonstrate how they normally do it.

Ask who washes their hand with a kettle?

Ask for a volunteer. Put palm oil on their hands and say it is shit. Ask them to wash their hands themselves using a kettle. It should show oil on the handle of the kettle. Ask participants to come and inspect the handle of the kettle. Explain that using the kettle can make your hands dirty with the handle.

Ask the same volunteer to wash their hands by putting their hands in the bowl of water from earlier. Explain that everyone is putting their hands in this, and it is not clean.

Ask the volunteer to dry their hands with the towel that it dirty and on the floor. Explain that hands should be shook dry rather than dried on a potentially dirty towel.

Ask – who knows what a tippy tap is? Show them the example (remove the lappa covering it). Demonstrate how it works by pressing your foot on the pedal and washing hands.

Ask – is there any way my hands can get dirty by using this? Do I touch anything with my fingers?

Explain – a tippy tap can be made out of very basic materials – an old plastic container (or bamboo), some wire, and some poles. Explain how it works, and the place for soap or ash.

Explain how the water used is minimal, but can be used to water a small plant. It can also be used to see if people are using the tippy tap or not (if the plant is alive or dead).

Ask – do you think you can make one of these using local materials? Yes, you don’t need new containers to make these. They can be a cheap investment to protect you and your family’s health!

Ask – where should we locate the tippy tap? Answer – ideally close to the latrine, and/or before the entrance to the house.

Invite members to try out the tippy tap using the soap of their choice from the demonstration range.

Ensure to have the tippy tap always there for every meeting, with water and soap, and encourage members to wash their hands before the session begins.

KEY MESSAGES on Handwashing

Even though our hands may look clean, they often are not really clean

Germs can be passed from one person to another through hand contact, and not washing hands before eating or child feeding, after defecation, or after cleaning babies kaka

Dirty hands can make you sick!

Washing hands only with water is not effective to remove germs

There are lots of different types of soap, you can use ash, local soap, and even nice smelling soap that makes you feel modern and attractive

We all need to construct tippy taps, and monitor the usage of our familiies and neighbors

Children must be taught when and how to wash their hands

Actions for handwashing

Make up a song about handwashing and teach your children

Build a tippy tap

Teach your family and children how to use the tippy tap and the importance of using soap

or ash

Session 7: Personal Hygiene & Skin Diseases Invite a local trader/hawker to attend to show-case their products or be able to sell at the end of the

session

Purpose

To demonstrate the importance of personal hygiene of individuals in the community

To demonstrate how lack of personal hygiene affects other people

To practice guiding other people towards improving their hygiene behavior

To identify ways of giving critical feed-back without offending

To demonstrate good personal hygiene practices

To demonstrate hygiene products and market them through social marketing approaches of desirability

To increase understanding on skin diseases and their prevention

Materials

Demonstration materials, including:

o Luxury and local soap (a range of products)

o A small mirror

o A toothbrush, toothpaste, salt, ash, and chewing stick (for toothbrushing demonstrations)

o A nail brush and nail clippers

o A table or bench to display a range of personal hygiene products

Body map

Bowl of clean water

Session Activities

1. Introduction

Explain that this activity will focus on personal hygiene in terms of how to tell people about their personal hygiene, body cleanliness and its importance.

ROLE PLAY – THE PROBLEM WITH SIRAH

Before the session, ask for 4 volunteers and request that they practice the play before the session. Then run the play about issues of personal hygiene to the audience:

Act 1: Fatu meets Sirah. Sirah has a bad breath/smelling mouth (Fatu tries to get away quickly)

Act 2: Fatu meets Isatu and tells her about the problem of Sirah

Act 3: Isatu Says: what about Abu-his body odour

Act 4: Isatu meets Sorie and tells him about the conversation with Fatu.

Sorie says: What about Fatu herself? Her hair and nails are in such a mess!

Stop the play: Thank the performers.

ASK: What were the problems here? Are these common problems? Why and how are they a problem? What are the causes of different kinds of bad smells? What can you do about them?

Collect suggestions.

Demonstrate good cleaning behaviors with volunteers and demonstration

aides:

Tooth brushing

Ask what people use to brush their teeth. Discuss:

Using a tooth brush and paste to clean the teeth

Using a stick to clean the teeth

Using ash to clean the teeth

Using salt to clean the teeth

Ask participants to discuss the effectiveness and ineffectiveness of the above method/ways of cleaning the teeth

Steps to brush teeth with a toothbrush – get someone to demonstrate brushing their teeth with a brush and paste and ask people what the important points are.

Tips for facilitator

Brush for at least two minutes.

Use a small amount of toothpaste

Practice proper toothbrush placement.

Make sure you brush each tooth including the ones at the back

Rinse your mouth and toothbrush

Store the brush somewhere hygienic

Pass around some demonstration items of the tooth brushing.

Show the chew stick and ask the best way to use it.

Nail brushing, clipping and filing

Ask how do we cut toe and finger nails? Ask for a volunteer.

Examine the finger nails of the volunteer. Are they dirty? Ask the audience to look at their finger nails and say if they are clean.

Ask if dirt under the fingernails is clean and tidy and if it can make you sick. Ask how you can clean under the nails? Ask the volunteer to quickly demonstrate nail brushing. Pass around examples of a nail brush.

Ask the audience to look at the length of their finger nails and toe nails. Are they clean and tidy? Ask the volunteer to briefly demonstrate nail cutting using the nail clippers. Thank the volunteer. Pass round examples of a nail file and nail clippers.

Ask – what do people use to cut their nails? Discuss how cutting with a razor blade is dangerous and can transmit diseases. Better to use nail clippers.

Using mirror and taking pride in appearance

Ask who uses a mirror? Ask when the last time they saw their reflection? Ask how people can be sure they are neat and tidy and attractive if they can’t see themselves? Pass round samples of mirrors.

Ask a woman volunteer to demonstrate using a mirror to check her appearance. Then she pretends to walk into the village. Ask other women to pretend to call to her and say she looks fine.

Ask a volunteer to pretend to be untidy, and walk into the village, and participants say things to them about their appearance. Explain that people’s feedback on your appearance is also like a mirror.

Invite a Hawker to demonstrate the different hygiene products, let them explain in their own way the benefits of the different products (they are likely to talk about positive features like nice smelling, attractiveness etc).

Show the audience the range of products available on the market to keep clean, tidy, modern and attractive.

Ask where these products are accessible, and where people can buy them. Possibly invite the hawker to say a few words.

How to tell people about their personal hygiene

Ask for 2 volunteers: one is member of the Community Health Club; one is bad breath (Sirah). Roles play: telling Sirah about her problem and what to do about it

Ask for another 2 volunteers: one is member of the health club; one is body-odor (Abu). Roles play: telling Abu about her problem and what to do about it

Ask for another 2 volunteers: one is member of the health club; one is messy-hair (Fatu). Roles play: telling Fatu about her problem and what to do about it

Discuss the plays:

Ask: What useful advice did the performers give about body hygiene? Are there any other good ideas you want to add?

Reinforces local practices and materials used for body cleanliness

ASK: How did the performers go about telling the other person about his or her lack of personal hygiene? What did they do and say that showed that they were being polite and respectful? Or being harsh?

Give a quick presentation on how to give advice respectfully

How to give advice respectfully

Focus on a particular action or statement: Be specific and avoid generalizing statements, such as ‘you always have a messy hair’ or ‘you never wash’ instead say: when you combed and plaited your hair the other it looked really pretty

Challenge the action or behavior, not the person: Be clear that you identify particular actions and behavior that the person can change. For example, say’ what don’t you try using this soap or cream, its smell is really nice

Combined a positive statement with the action or behavior that should be improved: Recognize and speak about the achievements of the person and then add what might be changed. For example say’ your house is looking really neat, you should try and fix your clothes so they look just as good

Show how you connect to a problem: People can learn as much from mistakes as from achievements. Therefore point to a problem you may have had and make the link. For example Say’ I have once had this problem of bad breath and what I did then was that I cleaned my teeth every morning and night and they began to shine and my breath became fresh too’

Make suggestions for alternative actions or behavior: Suggest alternative ways by asking questions such as’ I Wonder what would happen if you used ash to scrub you’re your feet; or have you considered using ash when you scrub your feet

Ask Participants to give their own examples for each of the five points highlighted above

Ask: Who can give us all advice on how to say difficult things respectfully and politely?

Skin Diseases

Scabies and ring worm

Purpose

To identify common skin problems such as scabies and ringworm

To understand how such diseases are spread

To identify ways of preventing the spread of scabies and ringworm

To learn about appropriate treatment of scabies and ringworm

Materials

Body map

Procedure

1. Introduction

ASK: Have you or your children ever had scabies? What did it look and feel like?

(There is a severe itchy rash, especially at night, and sores where the person scratched the itch and caused infections that are filled with pus.)

Ask someone to stand up and pretend to have scabies.

EXPLAIN THAT skin diseases are very common especially amongst children. They can make life

Very uncomfortable and yet they can be prevented and are easily treatable

2. Scabies: Signs and symptoms

Hold up the body map vanguard. Ask participants to come up and point to the areas where scabies occurs

Ask groups to hold up their drawings and confirm that scabies is mostly found between the fingers, on the wrists, on elbows, around the waist, on thighs and buttocks and between the toes.

3. Scabies: transmission

Outline the transmission of scabies.

Tip for facilitator:

Transmission of scabies

Scabies is a tiny mite or bug like a tick (‘tumbu’) that enters a person’s skin and tunnels just below the surface. It is spread by touching the affected skin or by clothes and bedding. For example, when a child scratches the itch the ‘tumbu’ gets caught under his fingernails and on his fingers and when he then touches another part of his body the ‘tumbu’ infects that part. It is also spread to other people by touching them or their clothing.

4. Ringworm: signs and symptoms

ASK: Have you or your children ever had ringworm? What did it look and feel like?

(Ringworm infections are itchy rings or pale patches/spots).

Ask participants to point on the body map vanguard where ring worm occurs. Confirm that ringworm infections appear mainly on the head in the form of bald spots where the hair does not grow, on the face under the eyes, between toes and fingers, on fingernails that become rough and thick, and between the legs, around the genitals.

5. Ringworm: transmission

Outline the transmission of ringworm.

Tips for facilitator:

Ringworm is a fungus that cannot be seen with the naked eye. It is spread by direct contact from person to person, and through indirect contact through clothes and bedclothes.

6. Treatment and prevention of scabies and ringworm

ASK: What is the treatment for scabies and ringworm, and how can they be prevented?

Prompt responses to include the following:

Treatment and prevention of scabies and ring worm

Scabies and ringworm are easily spread and all members of the household must be checked and treated, if necessary.

Personal cleanliness is very important. Wash the body carefully and thoroughly with soap or ash and hot water two or three times a day and especially before sleeping.

Keep the affected areas dry and exposed to the air or sunlight as much as possible.

For both scabies and ringworm you need to get medication or ointment from the health

center. Apply the ointment on all the affected areas, every day. Ringworm will take a long time to control and get rid of.

Shave the head of the person infected with ringworm.

Wash the entire person’s clothes and bedding repeatedly until the symptoms have disappeared.

Hang clothes on the washing line to dry – do not put them on the ground.

The infected person should sleep on a separate mat under separate covers.

Key messages

Ringworm and scabies are highly contagious – that is, they are easily spread from one person to another through direct or indirect contact.

If one person in a household is infected, all members of the household should be treated and all

Bedclothes and clothes that are shared must be washed thoroughly – otherwise re-infection will occur.

Personal cleanliness is very important in the treatment and prevention of skin diseases.

Action on Personal Hygiene

Make up songs about personal hygiene and keeping yourself clean, fresh and attractive

Suggest that in the next week, all participants practice telling one person how they can improve something about themselves. Remind them of the importance of respectful and polite communication!

Examine all members of your household, especially children under 10 years of age for ringworm and scabies.

Construct a clothes line

Take infected family members to the health center.

Session 8: The Body’s Immune System Purpose

To understand that our behavior can strengthen or undermine the body’s ability to fight infection

or prevent sickness

To identify behavior that threatens the body’s natural immune system

To identify behavior that strengthens and supports the body’s natural immune system

To understand the importance of immunization

Materials needed

Body map

Procedure

1. Introduction

ASK: Who is afraid of flies?

Listen but do not respond to answers.

ASK: Has it ever happened to you that you stepped into some mud, and when you came home and went inside your house, some of that mud got onto the floor and you left a dirty footprint?

EXPLAIN: You only have 2 feet for leaving dirty footprints – a fly has 6 feet! Imagine how much dirt a fly can leave behind!

ASK: Where do flies sit, where do you find them?

Invite 3 volunteers up. Ask one to be a young child with an open wound, a runny nose and watery eyes. One to be a fly. One to be kaka. Get the fly to fly around landing on the kaka, then putting its hands all over the child’s open wounds, over its runny nose, around its eyes.

EXPLAIN THAT when a fly steps onto your food or the sore on your body, or your child’s runny nose, it leaves 6 dirty footprints from the feces it sat on! So you should be afraid of flies – because they are very dangerous carriers of disease!

2. Our body’s natural defense system

ASK: What do you do when an insect is flying towards you? How does your body protect you?

Collect examples of how your body responds to threats.

Eyelashes protect your eyes, your nose will detect if food smells bad and you should not eat it.

Our senses act as a warning system.

ASK: What are other examples of your body protecting you from germs? Skin, hair, body fluids, saliva etc.

ASK: Can you get well without taking medicine?

Collect examples of how the body restores and heals itself, such as resting, eating well, keeping very clean.

ASK: At times if 2 people are sick, why does only one of them get better?

Discuss measures taken to recover – such as rest, healthy diet, etc.

3. Weakening and strengthening our bodies’ defense systems

EXPLAIN THAT our bodies have cells that act as a defense force and fight germ cells. These cells are part of what is called the ‘immune system’.

EXPLAIN THAT we want to look at ways in which we can help our bodies to prevent sickness, and ways in which we might strengthen our immune systems.

ASK: What things do we do that are bad for our bodies or the bodies of people around us, and can make us sick?

Examples given should include the following

Behavior that weakens our immune system

drinking alcohol and smoking

lack of personal hygiene including handwashing

lack of environmental sanitation

not resting

stress

eating the wrong kinds of foods / not enough of different kinds

not drinking enough clean water

Demonstration:

Ask for a volunteer to stand strong up in the front.

Ask participants to name bad practices that weaken the immune system (see list above), and once they name it, ask them to pretend to be that bad practice, and then stand next to and pull gently down on the person standing. Get more and more participants to be bad practices and pull the person down further (getting weaker and weaker), until eventually the person falls down.

ASK: What happened?

EXPLAIN THAT the body could no longer support all the bad habits and became weak and vulnerable to infection or sickness.

ASK: What are some of the things we can do to strengthen and support our bodies?

Ask the person that was standing to name habits they will improve to strengthen their immune system (e.g. quit smoking, drink less, sleep more, eat healthily etc). Each time he names one, the person representing that habit that is dragging them down gets off the standing person, allowing them to stand up bit by bit, showing them getting stronger. The volunteer will become stronger and stronger and eventually stand up and even jump.

ASK: What happened?

EXPLAIN THAT the body became stronger and stronger with all the immune boosting habits and better able to protect itself against infection and disease.

Ask participants to summarize the key messages.

Probe for responses such as the following:

Strengthening our immune system

eat enough foods that contain vitamin A such as pumpkin, yellow sweet potato, carrots, green leafy vegetables etc

get enough rest

manage stress, deal with problems and conflicts by talking to each other

wash clothes regularly

live in peace and unity with each other

do not smoke or drink a lot of alcohol

Ask each of the participants in turn what they think they could/will do this week to strengthen their immune system.

Key Messages

Our bodies have a natural immune system. That means they have ways of fighting threats to wellbeing.

The stronger and healthier our bodies are the easier it is to fight infections and diseases.

Some habits and behavior threaten the immune system, some strengthen it. Keeping clean, eating different kinds of food, resting and living in peace with each other are some ways of boosting our immune systems

Action

Ask participants to think about what they learnt in the session and decide what actions they will do within the next week in order to strengthen their immune system

Module 4. The Safe Water Chain

Session 9: Water Sources Potentially co-facilitate this session with a GOAL water supply technician for technical advice, and adapt the session to the types of water sources in the community.

Session objective

To understand the concept of contaminated water and link with sickness

To identify a variety of water sources and assess them in terms of advantages and disadvantages, and possible contamination pathways

To stimulate personal and community action to protect water sources / maintain protected sources

Materials

Rope and bucket used for drawing water from a well, and water transport containers (dirty)

Chalk or charcoal (for kaka mapping)

5 handfuls of ash for simulating kaka for the kaka mapping

A cup of water for splashing for the kaka mapping

Flash cards picturing water sources, open defecation, diarrhea, water contamination

Body map banner

2 clear/white buckets with clean, clear water

1 cube of brown maggi stock

Session Activities

1. Introduction: water sources

ASK: Where do you get your water from? What are the different sources of water you use in this community?

Collect a few responses.

Ask participants to name their village water source. Ask them afterwards to associate them with the above three categories (rain, surface water e.g. streams or ponds, or underground like wells, springs and handpumps).

ASK: What are some of the reasons for why you get water from one source or another? Why do you like that one?

Tips for Facilitators: Briefly discuss factors such as availability, distance, accessibility, purity, cost, habit and social factors involved when collecting water.

Ask participants to get into 4 groups; give each group 1 card with a picture of a water source. Explain that different water sources have different advantages and disadvantages.

Flash cards (left to right): stream; rainwater; spring; handpump; family well.

ASK: Discuss the advantages and disadvantages of the water source in your picture.

Give groups about 5-10 minutes to complete the task. Request each group to show their picture and talk about the advantages and disadvantages of the type of water source.

EXPLAIN THAT the purity of water is the most important factor when it comes to health. Some water sources are contaminated by urine, feces and other matter and may cause diarrhea; others are the source of worms.

Ask a member from each group to come forward with the picture. Ask participants to line up the pictures in terms of purity: from the cleanest and safest water source to the most contaminated and dangerous one.

Facilitator’s Hint:

Surface water sources such as streams, lakes and ponds are open to a wide range of contamination, e.g. upstream mining or defecation, defecation and garbage in the catchment, animals drinking and defecating, people collecting from them/washing in them and making them dirty.

Rain water is quite pure, but it can be made dirty by the dirt and animal (e.g. bird) kaka on the roof, especially in the first rains. Rain water can be collected by water draining from the roof of the buildings or from roof gutters into containers. The water containers it is collected in can be dirty, and animals can drink from them. In the rainy season, the rainwater will be much more pure than surface water or unprotected wells

Groundwater such as wells, springs, boreholes, handpump sources. This is rain that has collected deep underground over many years. Ground water should normally not contain any disease germs because as rain water seeps through the earth, the soil filters it and removes the germs. Groundwater can be sourced by digging a well, drilling a borehole or from a spring. The quality of groundwater can be affected if there are surface pollutants near the well/spring (e.g. stagnant water, rubbish, kaka) that can soak into the ground, and also if latrines are located nearby. They can also be contaminated through the process of collecting the water.

What water do you use if the handpump is broken or dry? Are you happy with this alternative source?

Ask - Do you think the water you drink is clean and safe? How do you know? By its colour? By its taste? By where you get it from (handpump rather than open well/stream)?

Bring out the body map. Ask a volunteer to stand up and pretend they have diarrhoea. Ask them to point on the body map where they have pain. Ask – what happens if we drink dirty water? What diseases can we get if we drink dirty water? Explain that drinking dirty water can make you sick, as it may contain germs from other people that could give you diarrhoea, fever, worms, cholera.

Demonstration:

Collect clean water in two buckets.

Show to participants a brown magi cube

Ask participants to smell it and taste it.

Ask them to tell what it is.

Does it have colour?

Does it have taste?

Ask two to three members of the group to turn their backs.

Put some magi in one of the buckets and mix it well.

Call the three group member and ask each of them to taste the water in the bucket and tell which one tastes magi.

Magi smells, human shit smells

Magi has colour, human shit has colour

But if we put magi or human shit in a lot of water we cannot tell it is there

Conclusion

We cannot always identify safe water only by smell and taste. There are germs in small quantities that can make our water contaminated and cause disease.

Demonstrating how kaka flows into water during the rains and other sources of water contamination

Ask the participants to draw a very basic map of the community on the ground using chalk or charcoal. Features should include the houses. Mark the water sources with a different symbol. Then ask someone to take a handful of ash and pour piles in the main areas where people open defecate.

Ask – what is the slope of the community? Is the kaka higher than the water sources? What would happen if it rains? Then thrown a cup of water across the ash piles in the direction of the water sources. Watch the ash flow towards/into the well. Ask – what happened?

Ask them to interpret the map. Kaka flowed into the well.

Ask – do you think a stream or lake or pond is easily contaminated, and likely to be dirty?

Ask- is an open well or swamp at risk of getting dirty in this way?

Ask – Is a protected well (with raised headwall) or well with handpump somehow protected? Explain that using water sources like protected wells and handpumps can keep you more safe as they are somehow protected from dirty water flowing in.

Ask – Is there a cost associated with maintaining a protected water source? Who is responsible to pay it? Do you pay for it? Why? Is drinking clean water not worth the money? Explain, maintaining the handpump costs money for grease, spare parts etc. The government policy is that communities pay for their maintenance.

Ask – apart from kaka flowing into the sources when it rains, how else can the water in the wells get contaminated?

Consider walking as a group to a well.

Visit to a well (or role play if this is not possible):

Get the group to all walk to the public water supply and/or the unprotected water source often used.

Demonstrate the following in role play/drama skit with volunteers:

Get volunteers to display lots of dirty practices around the well which may make it dirty, such as:

Washing close to the water source and letting the dirty water pool near it (and it soaks back to the ground)

A child goes to the toilet, does not wash his/her hands, then picks up the rope and bucket from the house, drags it on the floor through animal shit, and then puts the bucket into the well

Children throwing (dirty) things into the well for fun, and putting rubbish around the well

Dragging the bucket and rope along the ground before putting it in the well

Animals walking around the well and drinking / defecating

Ask – how can this clean water in the well be contaminated by us when we collect water?

Hold up the (dirty) rope and bucket. Ask – is there any way that the water in the well can be made dirty by using these? What will happen when I put this dirty bucket in the well? Collect answers.

Explain that people bringing their own containers from the house means lots of possibly dirty containers entering the water. The containers may not be kept in clean places (on the floor with animals etc). Explain that only one rope and bucket should be used, kept at the well, and rope and bucket kept off the ground and out of reach of young children and animals. People collecting the water should wash their hands before touching the rope and bucket.

Ask – what are other ways the source is contaminated by us?

See Facilitators hints below.

Ask – how can we improve our water source to prevent contaminating it?

Prompt for suggestions such as:

Raise the headwall so water can’t flow in, put a lid on the well, construct drainage so water doesn’t pool around the site, build a fence (with door) to avoid animals being close, fix cracks in the apron/headwall to stop water flowing back into the well

Make bylaws so that only 1 rope and bucket is used for the well, and that it is hung up from the ground with a pole

Put up a tippy tap close to but downslope of the well and enforce handwashing before collecting the water, make a bylaw about not washing or laundering close to the source or defecating close, not letting animals drink at the source, not constructing a latrine within 100ft

Contribute in labour, materials and cash to the upgrading and maintenance of the water source (all man’s business). Recognise that keeping a protected water source clean and working costs money.

Summarise:

Drinking dirty water can make you sick

Even if water looks clean, it may still make you sick

Use a protected water source like a handpump, and maintain it properly, and contribute to its maintenance

If using a well or unprotected source, look at ways to upgrade it, and for all water sources consider community bylaws to protect water source quality.

Keeping the water source clean is everyone’s interest, and everyone’s responsibility

ACTION

Visit the different water sources in the community to identify risks to water contamination, and hold a community meeting on how to address these, including possible upgrades to the

source, and establishment of bylaws. Discuss issues of funding the operation and maintenance costs of the protected water supply.

Establish a tippy tap next to each water source, and a clear system for who will maintain it

Erect a pole and designated water container for wells without a hadpump

Clear-up the water source area, improve the drainage/surface water inflow. Discuss who should be responsible to maintain the hygiene at the water source

Members to tell their family members and children what they learned

Make up a song on how to keep the water source clean

Session 10: Water Transport, Treatment & Storage Consider having a local retailer/hawker that sells plastic bailers, 5-gallon containers and veronica

buckets

IF WATERGUARD/LIQUID CHLORINE IS AVAILABLE IN THE COMMUNITY, A DEMONSTRATION OF THE

PRODUCT AND TASTE TEST SHOULD ALSO BE INCLUDED IN THIS SESSION.

Session objective

To understand the concept of contamination of water from collection to transport to storage

To understand the importance of safe water storage and explore ways of doing this

To review the different products that can be used for safe water storage

Materials

A rope and bucket

A bucket with no lid

A see-through clear water bucket, with clean water inside

A small cup for drawing the water from storage

Ink that can demonstrate water contamination from the bottom of a cup or hand dirtying the water

A small plate or dish for the ink

A table to put the water storage items on

A 5 gallon yellow water container with a lid

Examples of domestic water containers commonly used in the community

A small veronica bucket with a lid and tap

Body map banner

A long handled balier/scoop (like the ones used for body washing)

A container with very dirty water

A clean t-shirt or lappa that water can be strained through

Introduction

Ask a volunteer to pretend to have diarrhea. Hold up the body map and ask where it hurts. Ask did they get sick from drinking dirty water?

Ask/recap – can we get sick from drinking dirty water? If so, how?

Explain that drinking contaminated water can cause sickness like diarrhea, worms, fever.. In the last session we talked about protecting the water sources you collect the water from. Today we’ll talk about keeping the water safe and good quality from collection to drinking.

Safe Water Chain

Ask – do you drink water directly from the source, or do you take it home and drink it from there?

Ask for 3 volunteers to stand up. Put a rope and bucket in front of the first, call them Mr/Mrs Collection. Put a bucket with no lid in front of the next person, call them Mr/Mrs Transport. Put a clear bucket with a lid and cup on it in front of the last person, call them Mr/Mrs Storage.

Ask Mr/Mrs Collection to role play dirty practices that can contaminate the water when collecting (dirty hands, spitting or washing at the water source, hands all over the bucket etc).

Then ask Mr/Mrs Transport to role play dirty transport practices (dirty hands, putting hands in the container to drink etc, walk, stop and talk to a friend, put the container down and children/dogs drink from it), then carry to Mr/Mrs Storage and deposit water there. Stop the role play, and ask people to summarise what happened?

Ask – how can the water be contaminated when you collect it?

you drink clean water in your home? Are there ways that water can be contaminated in between?

Facilitator hint

These are the main sources of contamination along the safe water chain:

Key messages for collection and transport:

Use a designated container and rope hung up on a pole at the water point away from animals and children

Wash your hands before collecting and transporting drinking water

Wash the transport container if needed

Cover the transport container when transporting so it does not spill and can’t be contaminated

Don’t put your hands or cups into the water collected or play with the water

Role Play/Drama Skit:

Ask Mr/Mrs Storage to do a short role play. Bring the water bucket and cup or jug into the center and place them on the floor. Inform participants that they will now watch a short play about storing drinking water.

Without telling the rest of the participants instruct the volunteer as follows:

Collection

- dirty containers and hands put into the well

-unhygenic practices at the well

- dirty hands/bottles used to put the water into the container /

funnel from the handpump

Transport

- Using dirty containers

- dirty hands

-uncovered containers and animals drinking from them

Storage

- dirty containers

- dirty hands/cups dipping into the water

- no cover/lid, and animals/ children contaminate it, things

fall in

Imagine, this is your drinking water but you do not know how to protect water to keep it clean and safe. Behave in the worst possible way – do everything wrong, like spitting into the water, putting your hand in it to scoop out water, dipping the cup into it so your hand gets wet, washing your hands in the water, splashing each other from it – make it funny and fun!

Start the performance – stop it when the point has been made, clearly

Ask performer to scoop a cup of this water and offer it to participants. They should refuse to take it!

Explain that you want to talk about keeping water stored in the home safe.

Storage Container Location and Cover

Show an example of ‘normal’ water storage containers used in the community with water in them. Examples with/without lids, open buckets.

Ask – where do you keep your drinking water container? On the ground? On a shelf? Put the container with no lid on the ground.

Ask – is it covered? Always?

Ask – what is the problem if the water container is located near the ground? (answers around animals drinking from it, children putting their hands in).

Pick the container up and put it (without a lid) on the table or bench. Explain that the first thing everyone can do is picking it off the ground.

Ask – what is the problem if the water storage container is not covered? (answers around animals drinking it, things falling in it, rats drinking from it in the dry season..)

Ask – what is the solution?

Explain – water containers should be covered and located off the ground if needed. If not covered, animals can drink the water, and it attracts rats and insects into the house to drink in the dry season.

Explain that water containers should be covered.

Water Contamination Demonstration

Ask a volunteer to come to the front, and demonstrate how they normally take water from their stored water. Use a clear container with clean water.

Put the cup into ink on the tray, and a bit of the bottom of their hand (the bit that can touch the water when collecting). Put it on their fingers and hold the cup. Show the audience the ink. Explain that the ink represents germs on the bottom of the cup and their hands. Explain that the volunteer has a very dirty mouth with sores/disease on his lips. Ask the volunteer to pretend to drink water from the cup.

Ask the participants what they think will happen if the volunteer puts the cup in the container. Ask them to watch the bucket. Ask the volunteer to slowly put the cup into the container, show the ink running into the water.

Ask them what happened.

Explain that germs are invisible, so you may be contaminating the water without knowing it. Explain that by putting in the cup and your hand that you can contaminate the water.

Water Storage

Ask where people keep the cups? Are they special designated cups? Do different people use them? Ask if there is any risks of water contaminating them?

Demonstrate the long handled scoop and ask a volunteer to use it to scoop the water and pour it into a cup.

Ask – do you think using a designated long handle scoop would lead to less contamination than a common cup and putting your hands in?

Explain – using a long handled designated scoop, placed somewhere safe, and only used for drinking water, can be better than a cup.

Ask – if I drink straight from the scoop, is it bad? Why? Remember the volunteer has a very dirty mouth.

Explain that the scoop should be used to pour direct into a cup, otherwise your mouth will contaminate the scoop. Demonstrate pouring from the bailer/ladel into the cup and drinking from it.

Ask a volunteer to demonstrate pouring water into a cup from a yellow 5 gallon container.

Ask – is there risks of putting our hands in and contaminating this?

Explain that by pouring the water out rather than putting a cup into the water, it keeps the water clean.

Ask a volunteer to demonstrate pouring water into a cup from the tap of a veronica bucket.

Ask – is there any way you can contaminate this water?

Explain that having a tap means you pour from the bottom and don’t have to put your hands inside.

Summarize:

A good storage container should be:

Located off the floor

Have a lid on at all times

Allow taking water by pouring (yellow 5-gallon, or tap) rather than scooping

Is using a cup – use one with a long handle, or a designated long-handle scoop, located somewhere safe and only used for water, not to drink straight from.

Treating water

Explain – we have been speaking about keeping water clean from the clean water source all the way to your mouth. Now what about if you take water from dirty water sources?

Ask – do people treat the water they drink, when taking water from an ‘unsafe source’ (e.g. a spring or well that may be contaminated). If yes, ask how? Common answers include for surface water – settling, straining with a cloth, and sometimes boiling.

Explain that if collecting water from unsafe places, it can make you sick. Any water taken from streams, unprotected wells or swamps should be treated before drinking.

Explain that if the water is very dirty/muddy, it should be left to settle for 10 minutes in the container, and then pour into a pot to boil it leaving the dirt at the bottom of the container.

If it is very dirty and doesn’t improve by settling along, it could be strained through a cloth, as long as the cloth is clean!

Demonstrate pouring dirty water through a lappa or t-shirt to filter it.

Ask – is this water safe to drink now that it is settled and strained through a cloth?

Explain that the water may look clearer, but it is not clean. If you drink this water you are likely to get sick. This water should be boiled, bubbling for 3 minutes before it is safe to drink.

Ask – are all of our bellies and immune systems as strong as the other? What about old people, babies and pregnant women?

Explain that it is especially important to give treated water to old people, babies, sick people, and pregnant women, as they have weakened immune systems, and can get diarrhea easily if they drink dirty water.

Explain that water taken from a handpump or tap normally does not need boiling. But water taken from sources that are open to potential contamination should always be boiled.

IF WATERGUARD/LIQUID CHLORINE PRODUCTS ARE AVAILABLE IN THE COMMUNITY FOR HOUSEHOLD WATER TREATMENT, THEY SHOULD BE DEMONSTRATED HERE.

Key Messages:

Water can be contaminated and can make you sick if you drink it

Even if you collect water from the handpump, you can contaminate it during transport and household storage

People should use clean, covered containers to transport water

Storage containers can be easy places to make the water dirty. Storage containers should be raised off the floor and covered at all times

Good water storage containers are ones where you pour the water – a 5 gallon rubber or veronica bucket is good.

If using a scoop, use one with a long handle, used only for water storage, and pour into a cup not drink straight from it.

Water taken from a safe, handpump or tap source may be safe to drink without treating. But water taken from an open well, spring, swamp or stream/river should always be boiled before drinking.

Action:

Every household to review the way they store their drinking water and take steps to improve it before the next session (e.g. purchase a long handled bailer). Make household rules about how people take water from the storage container

Make up songs about water contamination and the safe water chain

Pass the messages to your family and children

Module 5: Total Sanitation (“Amu Kpoi Lowu”)

Session 11: The Importance of Total Sanitation (1)

Note – this session should be done as a whole community meeting, rather than as an individual club. There is likely to be a need for a meeting with the community leadership before this meeting.

The Sanitation Marketing masons could be invited to make a short presentation of their products at the end of this session (but NOT) get involved during the session.

Session Objectives

To understand how open defecation is resulting in the community eating and drinking their own kaka, and the health implications of this

To develop an understanding for the need for total sanitation, and to eliminate open defecation (Amu Kpoi Lowu) in their community

Material

A bag of ash or rice husks or other marker that can be poured to simulate kaka areas in the community

Charcoal or chalk to draw houses etc. in the kaka mapping and F-diagram links

A few cups of water to pour on the kaka map to simulate rain/water flow

Palm oil

A plate of food / bread (to show a fly landing on it)

A bucket with water, and cup/bailer/scoop

Flash Cards

Session Activities

1. Drawing a Kaka Map

Ask for a volunteer to come to draw a map of the community on the ground. Ask them to draw the main features. Ask:

Can you draw the main village road?

Where is the mosque or church?

Where is the school?

Where is the health post?

Where are the water points? Where is the stream?

Where are people’s houses?” For large communities, don't draw every house just cover the general housing areas.

”Where do the community get their water?” Use a different color/marker for water sources

“Where does the community go to the toilet?” Mark it on the map by piling ash/rice husks in the areas identified as defecation areas

Point to a house near the defecation areas, ask the owners “does this kaka here affect you?”

Point to mosques or public areas; ask them how kaka could travel to these areas.

What happens if a fly touches the kaka and then touches someone who is praying in the mosque, is this person still clean? Ask the imam what he thinks about this.

Ask, where do young children kaka? Mark the places with ash/rice husks

Ask, where is the baby and young child kaka thrown once cleaned? Mark the places with ash/rice husks

Ask, what happens when you do kaka here and it rains?”

Get the water in cups and start to pour it on the piles of ash/rice husks, to simulate rain. Throw the water in the direction of the slope, to show the direction the kaka water travels in.

Stop, thank the artist volunteer, and ask people to discuss what they have seen. The main topic of conversation should be that shit exists in the community, inside it, and around it.

Leave the kaka map on the ground, so you can refer to it later in the session.

2. The F Diagram

On a different (unmarked) area of the floor, lay out the F-diagram cards (kaka, fingers, flies, fields,

fluids, food, mouth), in the order shown below.

Explain that you want to talk about how some diseases are spread?

Hold up the body map flash card.

Ask, when you have diarrhea, which part of you does it affect? Get participants to mime having a problem in their belly. Ask, so is the sickness in our belly?

Ask, where does it go from our belly? Show that it goes out into the kaka.

Ask, do you know how diarrhea is spread? Do you know how bilharzia (schistosomiasis) is spread from one person to another? Do you know how worms are spread? Do you know how cholera is spread? Do you know how typhoid is spread? What about Hepatitis A? Polio?

Explain that all these sicknesses are caused by someone being sick, and the germs making them sick passing out into their kaka when they defecate. Use the body mapping flash card to demonstrate this.

Ask, how do these diseases pass from one person’s kaka to the next person?

Adapted from image sourced on www.nzdl.org

Explain that to get infected by these germs need to somehow get into a person’s mouth, that they swallow them, and it makes them sick.

Draw the transmission pathways using charcoal, linking the different pictures from the kaka to the next person’s mouth, as shown in the diagram above.

Ask a person to volunteer to pretend to defecate over the picture of the open defecator in the diagram. Pour ash under his/her bottom, to represent the kaka on the ground.

Ask participants to come forward and act how they think the kaka can pass along various transmission routes – role play various practices that make this happen.

Put a plate of food next to the food picture. Ask a person to volunteer to be a fly, and land on the kaka (ash), and then land on the food (with ash on it). Pick up the food, and offer it to participants. Will they eat it? Why not? Explain that by having shit in their environment, flies can transport someone’s kaka and put it on the food we eat. Ask, does that mean we are eating people’s shit?

Put the picture of a stream/well next to the ‘fluids’ picture. Ask, what is happening here? (people collecting water).

Put the picture next to the ‘fluids’ flash card on the F diagram on the floor.

Ask a volunteer to pretend to come collect water from where the picture is (next to the fluids picture on the F diagram). Give them a bucket and scoop/bailer to pour the water into.

Point to the kaka (ash pile) on the open defecation picture of the flash card. Ask, what happens when it rains? Take a cup of water and throw the water on the ash, so that it runs towards the fluids picture. Get the person pretending to collect the water to scoop up some of the ash water, and put it into the container.

Take a cup, dip it into the water, and offer it to participants. Will they drink it? Why not?

Ask, is this a problem in the community? Ask, does this mean that we are drinking people’s shit?

Summarise, is open defecation an issue?

3. Blocking the Transmission Routes by Sanitation

Return to the F Diagram. Ask how we can prevent diseases from passing from one person to another? Explain that we need to break/block the routes of transmission to stop the sickness, and stop eating and drinking each other’s shit!

Ask them to identify the different ways kaka can get into fluids. Ask for suggestions of how to block this? The answer is using a toilet. Use the charcoal to make a line blocking the line between the kaka and fluids.

Ask, how can we avoid feces getting onto our crops that we grow and eat (fields)? Answer, using a toilet rather than defecating in the bush. Use the charcoal to make a line blocking the line between the kaka and fields.

Sources: www.africanwellfund.org; www.washjournalists.worldpress.org; www.inpeerwater.org;

Ask, how can we stop flies moving shit onto our food? Answer, using a toilet? Ask, can a poorly built toilet control flies? Answer, no, it needs to have a cover over the hole to stop flies getting in and out. Use the charcoal to make a line blocking the line between the kaka and flies.

Note - You do not need to cover the other aspects of the transmission routes now, as the main focus in this session is on toilets.

Stand back, and ask participants to discuss if toilets would help stoping diseases and stop us eating and drinking shit in our community.

4. Total Sanitation

Ask, how many toilets do we have in use in this community? How many households do not have toilets?

Ask, if I have a toilet, but my neighbor does not use a toilet, is it a problem for me? Will it make me sick? How?

Ask, if all the houses apart from one used a toilet in this community used a toilet, is it a problem? Why?

Summarise that if the community is to be healthy, ALL households need to have and use the toilet.

Ask, is open defecation acceptable in this community? What can we do about it? Whose business is it in the community regarding the need for total sanitation? (response, everyone’s business and responsibility).

Discuss this for a while.

Discuss, does the term “Amu Kpoi Lowu!” (remove all open defecation in Mende) capture what we need to do in this community?

Start to chant it, and encourage all to start to chant it, building up energy and enthusiasm in the group.

5. Brief discussion about what can be done

Ask, Should we sit down and accept this? If not, what should be done about it?

Start a discussion amongst the participants about the issue of open defecation in the community, and what could be done about it. Facilitate, but try to let the community to develop their own ideas about what could be done. Explain that we will discuss issues about defecation when at the farm in a following session, so for now, focus on community sanitation. Explain that the next session will focus on developing a plan for sanitation.

Key Messages

Open defecation in the community is a big problem, causing diseases that could be prevented, and causing people and visitors to drink and eat shit! Open defecation should be eliminated! “Amu Kpoi Lowu!”

Sanitation is everyone’s responsibility, and if anyone is open defecating it is affecting not only them but the whole community

Proper toilets, that prevent flies is essential to prevent diseases and stop people drinking and eating kaka

Action

Community to consider chanting/making up a song about the need for total sanitation in their community (“Amu Kpoi Lowu!”)

To meet together as a whole community for the next session to discuss how to plan to achieve total sanitation (“Amu Kpoi Lowu!”)

Session 12: Planning for Total Sanitation (“Amu Kpoi Lowu!”)

Note – this session is to be delivered as whole community meeting, rather than as an individual club.

If the Sanitation Marketing artisans did not present their products at the last meeting, they should be

invited to do so at this meeting (but only at the end).

Session Objectives:

To think through and discuss the key considerations in achieving total sanitation in the community

To understand minimal requirements that all toilets in the community should achieve

To develop a basic plan for achieving total sanitation, including targets, timeframes, interim steps, monitoring and enforcement, and approaches to ensure all are included

Materials:

Flip chart paper and markers

10 vanguard

Cello tape

Ruler or straight edge to draw straight lines on the vanguard

Flash cards (F diagram, basic features of a toilet)

Charcoal/chalk to show the F diagram transmission lines

Community Deposits/Savings Box with the 3 padlocks/keys, ledger and pens

1. Introduction

Begin by recapping the previous sessions on total sanitation. What did we learn? What was agreed?

Prompt for answers such as:

The need to remove all open defecation, through household toilets

That sanitation is the responsibility of each household, and the overall community, as one person open defecating will affect the whole community.

Chant the slogan “Amu Kpoi Lowu” to get the community motivated again.

Briefly ask, what are the benefits of using a toilet? Prompt for answers not only including for health prevention, but also pride, convenience, comfort etc.).

Ask, so you want to remove open defecation from the community. How can we do this? This is a big task, do we need a plan on how we will achieve this, and need to monitor whether we are achieving it?

Explain that this session is about helping to develop a plan of action for total sanitation, to ensure it is achieved, in good time, and that everyone is included.

Defining Minimum Acceptable Standards for all Toilets in the Community

Quickly lay out the F diagram cards on the floor and draw the transmission lines. Ask participants to recap what it shows (how diseases spread from the kaka of one person to the mouth of the next person).

Hold up the flash card of the basic features of the toilet, and ask participants to identify the basic features – pit, slab, cover, walls, and roof.

Ask, what are the minimum features we need for our toilets to prevent diseases?

Point to the F-diagram ‘fluids’ picture – ask, how can we stop our kaka polluting our water (answer, using a toilet, and not putting the toilet too close to the well).

Point to the ‘fields’ picture, ask, how can we stop our kaka polluting our fields? (Answer, using a toilet).

Point to the ‘flies’ picture. Ask, how can we stop flies landing on our kaka? Answer – using a toilet.

Ask, do we need any feature on the toilet to protect against flies? Agree that a cover is essential.

Ask, what about the fingers? How can we ensure our hands are clean after using a toilet? Answer, having a tippy tap at the toilet.

Draw a tippy tap on the flash card next to the toilet.

Ask, in terms of stopping diseases, does it matter if the slab is made from concrete, or local materials? Answer, to stop diseases, the slab needs to be stable and no gaps (apart from the squat hole). This can be achieved using local materials or concrete slabs, so while concrete slabs are preferable, for those who can’t afford them, they can use local materials.

Ask, in terms of stopping diseases, if the squat hole is covered, does it matter what the walls or roof are made from, or if it even has a roof? Explain that the walls and roof are important, but more for user’s privacy and comfort than for disease control.

Summarize, what are the absolute minimum features that all toilets in this community should have? Agree that all toilets should at least have:

A stable slab with no gaps (but can be made from local materials or concrete)

A cover for the squat hole

A tippy tap outside the toilet

2. Digging Pits Any Time of Year

Ask, is it good to dig pits so deep that we hit water? What will happen if our shit is in the water?

Explain/prompt for answers including:

Defecating in the water will contaminate the water which we drink

Wet shit is more smelly than dry shit, and wet shit encourages breeding flies and mosquitoes

Source: www.ndzl.org

Adapted from image sourced on www.nzdl.org

The walls of the pit will be made less stable if it is in water, so may collapse more easily

Ask, should we dig pits that in the rains would become flooded?

Explain that pits should not be dug so deep that when the rainy season water level rises, it is in the pit. It is not a water well!! So that means that households can construct the pits in the rainy season, and not have to wait for the dry season when the water level is lower.

3. Defining the End Goal and Targets

Ask, so we all want to remove open defecation completely in this community, and to have basic hygienic toilets, is that right?

Explain that this session is to help the community to develop a Plan of Action in terms of achieving this objective of Amu Kpoi Lowu (start to chant).

Ask, to achieve Amu Kpoi Lowu, how many toilets need to be constructed?

Ask, based on the minimum standards we agreed on for toilets, do some existing toilets need to be improved a little? How many?

Explain that these numbers (new toilets and improvements) are the basic targets of the community action plan.

4. Discussion about Various Aspects Before Writing the Plan on Paper

Explain that before writing the plan, it could be useful to discuss ideas on various issues.

Allow discussions to follow amongst the community, and prompting to include items relating to the following:

Key Steps

Ask, what key steps are there to achieve the target of Amu Kpoi Lowu? Prompt for/expect answers such as:

Pit digging

Making/purchasing the slabs

Making/obtaining covers

Building tippy taps

Superstructure and starting to use the toilet

Discuss the practicalities of each step – who would do it etc.

5. Ordering Sanitation Materials/Services

Ask, do some of us want to buy materials/products to construct the toilets?

Ask, do we need to hire in labor to dig the pits?

Ask, would it be easier/cheaper to combine our order where possible? Could we encourage the trained masons to come to the community if we have a big order, rather than one by one?

Discuss for a while.

Ask, do we need to start to save our money ready to buy in bulk?

Do we need to make deposits?

Ask, when will we have money? Should we save it while we have the chance during harvest?

Saving for the Sanitation Products / Deposits

Ask, how can we save for the toilet slabs etc., and how can we combine our orders?

Discuss various ideas for how the community could save for the toilets. Explain that a toilet is a household investment, and that people may want different types of products, so doing it by all households making fixed weekly contributions may not be the best way to buy the toilets.

One idea includes the deposit box and register.

Introduce the deposit box (padlock with 3 keys).

Explain the concept:

The box is a secure place where funds are placed for the deposits, which can be used to combine the orders. It can be seen as a kind of bank, where each household has an ‘account’ where they save or deposit their money.

All deposits are recorded in the ledger book, showing what was saved, and for what product.

Households make their own deposits for the products into the box – this can be as much or as little as they want for that particular week. Explain that as this is harvest time, households can make one-off deposits if they have the money, or can add to ‘their account’ each week.

Individual clubs/members can have separate savings and loans/osusu systems, so that they can raise the money to put into the box. Alternatively households can put money to ‘their account’ in the box each week. Explain that it is probably easier that the osusu/loans aspect is kept separate from this box, so that the money is not confused.

Discuss if this is an appropriate way, and if so, how it could be organized, how it could be managed, how to ensure transparency?

Note – this approach is only one approach, and should not be pushed on the community. They should decide for themselves how they will plan and save for the costs of sanitation.

Inclusion, Land Access

Ask, are there people in our communities that may have problems achieving the targets? If so, what can be done? Emphasize the issue that any open defecation in the community is a problem for the whole community.

6. Writing the Plan of Action

Ask, should we have a plan written down, so we can agree on what we need to do, and by when?

Provide the flip chart/vanguard and markers.

Ask, what key features should the plan contain? Prompt for answers including:

Numbered targets (e.g. 8 pits)

Key steps to take

Timeframes/deadline

Ask, would it be useful if the plan includes somewhere if we can mark off when it is achieved, so we can monitor progress?

Examples of possible plans could be similar to the following- however allow the community to develop the structure and content that they want.

Prompt the community to start to develop the plan. Stand back, and let the discussions/writing happen, and be careful not to take over/overly influence the process.

Emphasize that a properly dug pit would not dig down to the rainy season water level, so there is no need to delay pit digging until the dry season.

Monitoring, Progress Review, Enforcement & Encouragement

During the process of developing the plan, prompt questions such as:

Ask, should we keep a track of the progress to the plans, as a community?

Ask, how can we monitor progress to our targets? How can we address issues?

Ask, what should we do if targets are not being made?

Ask, should we recognize the households that make progress? How?

Ask, while we take time to construct toilets, is there anything we can do to ensure there is no open defecation in our community? Example ideas could include an agreement around sharing existing toilets, and/or use of cat sanitation (burying the feces)..

7. Community Agreement

Once the plan is developed and agreed on, some communities may also want to develop a community agreement/Memorandum of Understanding (MoU), which all households agree to/sign. This could be suggested, but not pushed for.

Summary & Actions

Take note of key actions that the community agree on, and ask the community members to summarize what is going to happen after/as a result of this planning session

Explain that the next session will focus on how to construct hygienic toilets.

.

Annex to Sanitation Planning Session: Facilitator’s Notes

The following notes are to help the facilitator prompt questions during the process if needed, to ensure key issues are discussed:

Initial Agreements:

Agree on minimal standards to be achieved

Agree on when should achieve zero open defecation, and achieve all minimal standards for toilets

Define number of toilets needed to be constructed, and time to achieve this

Define the changes needed to improve existing toilets

Agree on interim steps to be followed whilst waiting for the toilets to be constructed – cat sanitation, toilet sharing, child feces

Define monitoring measures for progress

Define punishment and enforcement of bylaws, put timeframes, and stick to them!

Who should be leading this process? Who should we involve?

What can we achieve as a community, what do we need assistance for? How can we get this?

Financing:

What items do they need money for, and what will it cost? (Note will vary by household depending on pit digging, availability of materials, and level of upgrade they want to get to?

When will they have money?

How can they save the money?

How can they manage the money in a safe, accountable way?

How can they help those needing money to achieve the plan?

Who will liaise/pay with the masons – household or community?

Pit Digging:

Where are the toilets going to be constructed?

Who will dig the pits?

How will the pit dimensions be correct, and monitored for this?

Ordering/Sourcing the Sanitation Items/Materials:

How can the community combine orders where relevant to attract the services of artisans, and reduce transport costs?

Who can organize the collection of orders and finance

Who will liaise/pay with the masons – household or community?

Monitoring, Tracking, Problem Solving and Punishment during construction:

How will monitoring of progress to the plan be done?

How will progress be reported, and to who?

How will the progress be reviewed, and how can problems be addressed and resolved?

What interim indicators will we track (e.g. to pit level, to slab, cover, handwashing, superstructure, operational

Ongoing Encouragement/ Mobilization:

Who should do this?

How should this be done?

Competing and Recognizing Achievements:

How could progress be recognized formally?

Should clubs/households/communities/sections be competing against each other regarding progress, and how could winners/progress be recognized?

Example of a Community Total Sanitation Action Plan

Note – this is an example only, and communities should be encouraged to develop their own ideas of how this plan should look like and contain.

Task Number / Name

Deadline Progress Monitoring (mark date for each week)

Session 13: Building a Hygienic Toilet

Note – Sanitation marketing masons should be invited to this session if they have not already visited the community, and given the opportunity to present their products at the end of the session (not before).

Session Objectives

To understand the main features of a basic hygienic toilet, and a basic understanding on decisions on how/where to construct them

To identify possible upgrade options for toilets

Materials

Palm oil

Dish for the palm oil

Vanguard

F Diagram Flash Cards

Flash cards on latrine features

Sanitation Marketing artisans/marketing materials/product examples

A locally made squat hole cover with a handle

A locally made/sourced cover that can be operated with the foot (e.g. flat piece of wood)

Plastic kettle

Tippy tap

Session Activities

1. Introduction & Recap on Total Sanitation and Need for Toilets

Recap from the last sessions (total sanitation, sanitation planning). Chant Amu Kpoi Lowu, to get the participants energized/motivated.

.Ask, what are the benefits about having a toilet? Quick answers relating to health, and also dignity, comfort, convenience etc.

Minimal Design Features for a Hygienic Toilet

Ask a volunteer to draw on a vanguard the main features of a pit latrine. (Use the flash card to help). Mark on:

Pit

Slab (don’t specify if it a concrete or local slab)

Squat hole

Superstructure (walls/door)

Roof

Lay out the F-Diagram cards and draw the connection lines (like in the total sanitation session).

Source: www.ndzl.org

Ask participants, what are the most important features of a toilet to break the disease transmission? Ask them to mark on the latrine drawing:

Covered so that flies cannot enter/exit

Have a handwashing facility

Agree/recap that having a pit toilet that is covered, with a handwashing facility is the minimum needed to prevent diseases.

Explain that toilets can be basic (locally made) and still hygienic. Toilets can be more expensive/better quality (e.g. having concrete slabs, zinc roof etc.), but that this is not essential to break the disease transmission. Note that whilst all households having concrete slabs etc. would be good, but some may not be able to achieve this straight away, so better they at least have something to stop open defecating while they save money to upgrade later.

A stable, cleanable slab (using local or purchased materials) free from feces

A squat hole cover (other fly control options are discussed later in this section)

Ask, how do we clean ourselves after defecating? Ask participants to show cleaning/wiping.

Ask, are we likely to have kaka on our fingers after defecating? If so, what else does a minimum toilet need to have?

A handwashing facility with water and soap/ash

Explain that this is the minimum standards for health. The superstructure (walls, roof and door) are more for user convenience/comfort/dignity than disease reduction. The superstructure can be upgraded through time. The quality of the slab and superstructure can be upgraded in time.

Agree that the minimum that the community should accept, and the minimum they should aim for urgently is a toilet with a cover, a cleanable slab free from feces, and a handwashing facility with soap/ash and water.

2. Key Features of a Hygienic Latrine

Location of the Toilet

Ask, what do we need to think about when siting our toilets?

Point to the F diagram (the fluids part).

Ask, how can we ensure our toilets do not contaminate the water sources?

Explain that toilets should be located at least 30m from the nearest water source, as the water underground can get contaminated and move to the well. If it is more than 30m away, the germs will not reach the well. Explain that the soil acts as a filter removing the germs.

Ask, should the toilets be upstream of the water source? Explain that the water underground flows downhill, so toilets ideally should not be immediately upstream of the water source.

Ask, how close should the toilets be from our homes? Explain that ideally toilets should be 6m from the nearest house/kitchen area, but then not too far to be inconvenient to users.

Adapted from image sourced on www.nzdl.org

The Pit

Depth

Ask, how deep should the pit be? Should we dig down to the water table? Why?

Explain that the pit should be at least 1.5-2m above the highest level of the water table (the rainy season level), so that it does not contaminate the groundwater, and the soil acts as a filter. Explain that having a wet pit can also destabilize the pit, and can make the shit liquid can encourage fly and mosquito breeding.

Explain that how deep to dig the pit will depend on how deep the water table is at that site. Areas that are swampy/shallow groundwater should be avoided.

Sourced from www.helid.digi.collection.org

A guidance depth suggested by participants in the training was 3m, if the rainy season groundwater level is likely to be 1.5-2m deeper than that at that location (e.g. groundwater is at least 5m deep in rainy season).

Explain that if using a slab that can be moved (e.g. wooden slab or concrete slab), once the pit is full, the pit can be covered, and the slab moved to a new pit. This means the pit does not need to be designed to be deep enough to use for 50 years! We are digging a toilet not a well!

Explain that a full pit is full of nutrients, so a fruit tree can be planted in the old covered pit, and will grow healthy.

Diameter

Explain that a wide pit needs a very strong slab, so the pit does not need to be very wide. Explain that the Alafia dome slabs available are 120cm wide, so if the household ever plans to put a slab on the toilet (now or in future when money is available), the pit should be narrow enough to put a slab on it.

Discuss what would happen if the household dug the pit too wide – it would be a problem to put on the slab later..

Explain that the pit is much more stable when dug as a circle than a square. A recommended pit diameter is 60cm.

Note – a narrower than strictly necessary diameter (60cm) is recommended, to reduce the need for pit lining, and allow an error margin whilst pit digging. Therefore if people dig pits of up to 70-80cm, they may still be OK, but the recommendation should firmly be 60cm.

Ask, how can we dig pits to make sure we are making them the correct size (60cm diameter)?

Suggest that a pole could be cut to this length (60cm), and used as a marker for those digging pits/monitoring it – on the surface, and whilst inside the pit. Discuss this, whether the pole should be marked specifically, who should monitor the size, how the pit diggers will know the correct dimension etc.

Pit stability/lining

Should the pit be dug in loose sandy soils, or firm soils? Why? Explain that stable ground is needed to ensure the stability of the pit.

If the community is generally covering unstable/sandy soils, then further guidance should be provided by GOAL regarding options of lining. This could include using oil drums with the bottom removed, and sides punctured to release fluids. Brick lining can also be necessary in some areas.

Covering the pit until the slab is placed on it

Agree that the pit should be marked and have a temporary cover/marking or even possibly a basic fence whilst it is waiting for the cover, so that it does not become a risk to children/animals.

The Slab

Stability

Image adapted from source: wikiwater.fr

The slab should be made of strong materials that can take the weight of a very heavy adult over the pit. Slabs can be constructed out of different materials. The slab can be mobile, and can be replaced (depending on the superstructure above it).

Discuss what different options there are to the community for slabs. Discuss ideas of making them out of strong local wood. Discuss concrete options.

No Gaps

Ask – apart from the squat hole, should there be any other gaps/holes in the slab? Should it covert the pit tightly?

Explain that the slab must cover all areas of the pit (apart from the squat hole), to avoid flies and other pests entering in and out.

Mounded Edge

Ask, how could we ensure that soil does not collapse on the edge of the pit?

Ask, how can we ensure that water flowing on the ground in the rains does not enter the pit and flood it?

Explain that the slab should be placed on slightly mounded ground, so that it is already raised about the ground level, then the edges of the slab should be mounded sloping away from the slab, and tightly packed down to prevent animals burrowing.

Squat Hole

Ask, how big does the squat hole need to be? What shape should it be?

Ask a male and female volunteer to stand up and demonstrate using a toilet, aiming into a hole. Make the hole square and small. Ask, is it difficult, especially to get the urine in? Discuss the need to have space for urine and shit to come out when squatting.

Explain that the hole can be rectangular or key hole shaped, not square or circular.

The size is important – a hole too big can be a risk for children using it, and difficult to cover. A hole too small can mean that urine/kaka is sprayed on the floor.

Easy to Clean

Ask, should the slab and squat hole should be smooth or rough? Discuss. Explain that the surface should be smooth to allow easy cleaning.

Ask, what would happen if the edges of the squat hole are rough, and someone misses the hole? Explain that the shit would cling to the rough edge. The sides of the squat hole should be smooth and easy to clean.

Ask, should the slab allow water/urine to pool on it? It should be designed so that the liquids flow into the pit.

Image adapted from source: www.collections.infocollections.org

The Squat Hole Cover

Ask, do flies like entering the toilet? Ask, do flies breed in shit? Explain that up to 10,000 flies can breed from 1kg shit.

Ask for a volunteer to pretend to be a fly, and fly into the pit, land on the kaka, lay eggs in the kaka, fly out, and land on food. Then the eggs all hatch and lots of flies are flying around.

Ask, for those who have had toilets before, were flies a problem? What can be done about it? Discuss the need for a squat hole cover.

Ask, if a toilet does not have a cover, is it good for our health? Explain that the cover is an essential feature of the toilet.

Fit to the squat hole with no gaps

Ask, how big should the cover be? What should its features be? Explain that it should be big enough to easily cover the squat hole, with no gaps. It should lie flat on the ground with no gaps on the floor. It should not be too large to stop it being easily moved to the side out of the way of the user of the toilet.

Moving it

Role play - Ask a volunteer to stand up and pretend to use the toilet. Put palm oil on their fingers to represent kaka from anal cleansing. Ask them to then pick up the cover by the handle, and show the palm oil (kaka) on the handle. Ask a volunteer to be a fly and land on the handle. Ask another volunteer to use the toilet, and touch the same handle when moving the cover, getting the kaka on their hands.

Ask, how can we have a cover for the toilet that fits well, but that we don’t need to touch with our kaka fingers?

Introduce the idea of a cover that can be pushed with the feet.

Handwashing Facility

Ask the volunteer to come back and demonstrate cleaning themselves after defecating. Ask, where on our hands do we get kaka? Explain that it is on the finger tips and palm. Get the volunteer to put palm oil on these part of their hand.

Ask, do we need to wash our hands after defecating? Agree that we need to wash our hands after defecating.

Location of the Handwashing Facility

Ask, where should we locate the handwashing facility? Ask the volunteer with kaka hands to walk from the toilet after defecating to the house, go to the tippy tap near the kitchen, but get distracted, and shake hands, touch children etc.

Ask, where should we have the handwashing facility? Explain that the facility should be located right outside the toilet, to be sure that it is used straight after defecating. This is essential to break the disease chain.

This means that households should have two tippy taps – one for the toilet, one for the house/kitchen area.

Type of Handwashing Facility

Ask a volunteer to pretend to defecate, then clean themselves with the kettle. Put lots of palm oil on the fingers to represent kaka.

Ask, what do we normally use to clean our hands after the toilet? Ask the volunteer to wash their hands with the kettle, passing the kettle from hand to hand. Show that the palm oil is now on the handle of the kettle, and still on the hands of the person.

Ask, do we need to touch the tippy taps with our hands when we use it? Is it a better method to wash our hands after defecating?

Ask, should we only use water for the tippy tap? Agree that we need water, soap or ash. There should be someone responsible for refilling the water/replacing the ash/soap periodically so it never runs out.

Superstructure, Door and Roof

Ask, what is the purpose of the superstructure (walls/door) and roof? Explain that as long as the pit is fully covered with a slab and squat hole cover, the superstructure and roof is only for the convenience, comfort and dignity of the user (not so much for health benefits).

Agree that the walls and door can be temporary at the beginning if needed, and upgraded through time.

The door can be made from wood, sheet etc. Minimal hand contact to open it is preferable.

Discuss about other ideas for constructing the walls and roof.

Ventilation in the superstructure

If the toilet cover is kept on at all times, the inside of the superstructure does not need to be kept dark, and can be made to have some gaps between the roof and the top of the walls to allow air flow to move through the structure and ventilate to stop it being too smelly for the user.

3. Summarize/Agree the Minimal Requirements for a Basic Hygienic Toilet

Explain that the above features are the minimal requirements needed to construct a basic, hygienic toilet. Ask participants to list the key essential features:

A stable pit, located away from water sources and not dug into the water table

A stable, easy to clean slab that seals the pit effectively

A tightly fitting squat hole cover

Walls (and maybe a roof) to allow privacy and comfort to the user

A handwashing facility outside the toilet

Prompt the community to agree that all toilets to be constructed should meet these basic requirements.

Ask, what about the toilets that are already constructed? Do they meet these standards?

Prompt to agree that the existing toilets that will continue to be used should be improved where needed to meet these minimum standards.

Disabled Features for Toilets

Ask a person with bad knees/pretending to have bad knees to demonstrate squatting. Ask, what about people who have disabilities – how can we make sure the toilets are usable? Show the flash card below to demonstrate there are designs that can be included to make sure elderly/disabled people can use the toilets.

Possible Upgrading of the Toilet Source: HydroConsiel 2014

Discuss that from these basic features, a wide range of possible upgrades are achievable to the toilet, depending on the household’s purchasing ability and priority.

Note – this aspect of the session could be facilitated by the sanitation marketing masons to demonstrate their products.

Explain that households can build a higher quality toilet from the start, or progressively improve their toilet through time.

Discuss options for upgrading the toilet from this basic level. Options could include:

A concrete slab

Adding a toilet seat, especially for old people/infirm

A pour flush pan

A zinc roof

A concrete/pan body superstructure

Ventilation pipe and fly net

A shower slab and soak away

Note – to keep the session as simple as possible, aspects such as VIP, and pour flush were not introduced at this stage. A separate sanitation manual could be relevant for this.

Key Messages

Total sanitation/zero open defecation is essential to stop the community getting sick and eating/drinking their own shit

There are a lot of benefits in using a toilet, not only for health benefits (dignity, convenience etc.)

But a badly built or maintained toilet can be a health risk

Hygienic toilets should at minimum have a stable sight fitting slab, a squat hole cover, and handwashing facility

Households should achieve this minimum standard (for new and existing toilets), and can upgrade from this if/when they can afford to

Like building their house, building a toilet is the responsibility of the household, and they should not expect a subsidy or support from NGOs/Government.

Session 14: Total Sanitation 2. Child & Farm Sanitation

Session Objectives

To understand the issues of poor child excreta management and actions to improve it

To understand the issues with open defecation whilst on patrol/in the farm, and what can be done about it

Material

A bag of ash or rice husks or other marker that can be poured to simulate kaka areas in the community

A bucket of water and cup

A plate of food / bread (to show a fly landing on it)

A bowl (that would be used to wash a child’s nappy/rag in)

Rags that are used as child’s nappy/cloth to clean a babies bottom

A child’s stool (plastic potty) – covered

A child’s stool (plastic potty) – uncovered

A hoe

Session Activities

6. Recap from previous sessions (total sanitation)

Ask, what did we discuss in the session on total sanitation (Amu Kpoi Lowu)? What did we learn?

Prompt for answers including:

How open defecation is making us sick, and how it is causing us to eat and drink our own shit

How toilet construction is needed, and toilets should be covered, to protect the community from the diseases and shame

How the community needs to totally remove open defecation, as it only needs one person open defecating to make the whole village sick (chant ‘Amu Kpoi Lowu’ (zero open defecation))

How all households should have and use toilets

Explain that toilets are important for children and adults in the community, but does this cater for all kaka in our community? What about babies? What about young children too small to use the toilet?

What about when we go to the farm?

7. Is Children’s Kaka Dangerous?

Ask, do our babies and children shit?

Ask, does the kaka from our children contain diseases? Do they get worms? Do they get diarrhea? Is their kaka dangerous? Explain that our children/babies’s kaka is just as dangerous as adult shit.

Ask, would they be happy to eat or drink their neighbor’s child’s kaka?

8. Baby Sanitation

Ask, what do we do with the kaka from babies?

Role play – ask two volunteers to stand up, one a mother, one a child. Use ash to demonstrate the kaka from the baby.

The mother gets kaka (ash) on her knee, then wipes it with a rag, washes it carelessly in a bowl, then throws the water/rag onto the street. Show other bad practice. Show another child crawling on the floor, and putting their hands into it, then into their mouth.

Ask a volunteer to be a fly, and land on a plate of food. Offerthe food to someone – will they take it?

Ask, is this a problem? What can we do about it? Does this mean that we are eating our children’s kaka? Would you be happy to eat your neighbor’s baby’s kaka?

Where can we put the baby shit and kaka water from washing them?

Prompt for answers such as:

Disposing any baby shit, or the kaka water, into the toilet, and covering it.

Washing your hands after cleaning a baby

Washing the rag/cloth thoughly and hanging it off the floor in the sun

9. Young Child Sanitation

Ask, where do the young children go to defecate? Those that do not go to the bush? Where do we dispose of it? Can they use the latrine? (no they are too young). Show the flash cards if needed to prompt answers.

Ask some volunteers to be a young child defecating on the floor, and a mother coming to clean it (later) carelessly, and then throwing it behind the house/into the bush close to the house. Ask a volunteer to be a fly that lands on the shit, and offer the food that it lands on to participants. Will they eat it? Ask, what happens to the kaka they threw in the bush when it rains?

What could we do about it?

Ask, is it OK for our children to be defecating anwhere? Should we allow this? If they are open defecating at this age, will they grow up learning that open defecation is OK?

Discuss that a young child will be too small to use a toilet, so they need something to use while they are small.

Ask, does anyone here have a toilet for the young children (a plastic stool/potty)?

Ask volunteers to be a fly, a young child defecating in the plastic stool (the uncovered one), and a mother leaving the stool for some time, putting it near the house uncovered, then finally disposing of it in the bush near the house. Use ash to simulate the kaka.

Ask, are these potties available? How much do they cost? If we cant afford this, should we be covering our existing plastic stools with something, to prevent flies?

Ask, where should we dispose of the kaka?

Source: www.nzdl.org

Source: www.babybjorn.co.uk

Ask, do the children know how to use these stools? Do we need to teach them patiently so they learn?

Ask, is it a problem to you if a neighbor is careless about the feces of their babaies and children? Ask, if they don’t, may you be eating and drinking their shit, or walking in it after the rains?

Ask, what would you do if you see a neighbor doing bad practices?

Summarise:

Young children should be taught to use plastic stools

The stools should be covered to avoid flies

The kaka should be disposed of in the toilet ONLY

The child/mother should wash their hands after defecating/cleaning the plastic stool

Children and babies kaka can make you sick, and the community should not accept bad child/baby sanitaton practices. (chant ‘Amu Kpoi Lowu’ (zero open defecation))

10. Options for the Farm

Explain that in the next session we will talk about the features of a good toilet, and constructing toilets in our village.

But what about what we do when we are on patrol/in the farm?

Options for the Farm / Interim before Toilet Use (Cat Sanitation)

Go the the street/a place nearby where a small hole can be dug in the ground. Pretend that you are all going to the farm.

Ask a volunteer to do a skit about walking in the bush/working in the farm, and needing to defecate. Pour ash/rice husks under their bottom to simulate the kaka. The person walks off and leaves the kaka there.

Ask a volunteer to pretend to be a fly, landing on the shit, breeding on the shit.

Explain that the person has defecated close and uphill from the farm. Ask, what will happen if it rains?

Ask, what happens if it is upstream of our stream that we drink from?

Ask another volunteer to come with a hoe, and dig a small hole (about 10cm deep), and then defecate inside. Pour ash in the hole to simulate the kaka. Ask them to then re-bury the kaka.

Ask the fly to come, and fly around the 2 sites of defecation, preferring the open kaka to the buried kaka.

Ask, if it rains, will the kaka flow as easily if it is buried?

Ask a volunteer to stand 1 meter downslope from the kaka/buried kaka, and pretend to be farming. Explain this is the farm where the crops we eat are.

Ask a volunteer to stand a couple of meters down hill, pretending to collect water. Explain that they are collecting water that we are drinking.

Pour water over the first (open, not buried) kaka site (pile of ash). Pour the water so that it goes through the ‘farm’, and the ‘farmer’ volunteer collects food from the ground after the kaka passes over it.

Flow the kaka water down to the ‘stream’, where the person will scoop it up and put it in their bucket.

Ask, if we open defecate in the bush/farm, can it contaminate the food we are eating and drinking?

Pour the water over the covered (buried kaka), and show that it is somehow a bit better.

Ask, if we bury the kaka, will it easily flow in the rains? If we bury it, can the flies get it?

Explain that a basic measure to improve open defecation in the absence of a toilet is called ‘cat sanitation’.

Recap on Total Sanitation / Amu Kpoi Lowu

Recap that the community has said that shit is all around the community, and making them sick, and making them eat and drink their own shit without knowing it.

Recap that the shit is from adults, children, babies, and from open defecating whilst in the farms

Ask, what should be done about this? Should we sit down and accept this? If not, what should be done about it?

Ask, should we continue to allow open defecation in our community? Should we allow people to dispose of the baby and child’s kaka carelessly?

Key Messages

Open defecation in the community is a big problem, causing diseases that could be prevented, and causing people and visitors to drink and eat shit! Open defecation should be eliminated!

Sanitation is everyone’s responsibility, and if anyone is open defecating it is affecting not only them but the whole community

Children’s kaka is also a problem, and needs to be properly managed and disposed of, just like adult’s kaka

Proper toilets, that prevent flies is essential to prevent diseases and stop people drinkng and eating their own kaka

A basic improvement to open defecation, especially for the farms, can be cat sanitation.

Action

Community to discuss together how to address the issue of open defection, and develop a plan of action, that includes adult and children’s shit

To make up a song about open defecation/sanitation issues

Module 6: Hygiene

Session 15: Domestic and compound hygiene

Session Objectives

To understand the link between a dirty living environment and diseases

To identify current issues in their community regarding domestic and compound cleanliness

To understand various actions that can keep the house and compound clean, including waste and wastewater management, pot racks, and clothes lines – including design features and location of the facilities

Material

A couple of examples of cooking pots, plates and spoons/cooking utensils

A constructed pot rack (if available)

A local raffia broom

Other domestic cleaning items – brooms, scrub, disinfectant

An example of local household ‘bin’ (e.g., bag or rice sack) with food waste inside

A bucket with a lid to be used as a bin

Gravel to explain the materials for a soak away

A hoe or spade to dig the soak away

Clothes to show drying on the floor/clothes line

Flash cards of dirty environment (5 cards needed), of the rats/flies/cockroach, of the soak away, of the pot rack.

Session Activities

1. Introduction

Ask – can a healthy environment (our houses and village) keep us healthy? Can a dirty environment make us sick?

Ask for responses about how a dirty home and compound can make you sick? How?

Show flash card of bad sanitary habits, and divide the group into smaller groups of 7-8 people to discuss what the issues on the flash card are. Ask them to briefly present back to the group, through a role play/skit of what the issue is and how it makes you sick. Ask them to include other issues that may not be on the card but exist in the community.

Issues to prompt them to identify include: open defecation; cooking pots on the floor and animals eating out of them; pooled waste water and garbage being sites for mosquito breeding; garbage on the floor attracting rats/cockroaches; clothes on the floor (can get worms); animal kaka on the floor where the baby is crawling..

Ask – are these issues present in our homes and communities? If so, which ones are the big issues?

Ask, do our babies crawl on the floor of the communities? Is the floor clean? Is this an issue? Probe for answers on people not disposing of their child/animal’s feces etc.

Throw some waste onto the floor in front of the participants. Leave it there. Ask, are you happy with this? Ask someone to come to sweep it, but then throw the waste carelessly out of the barrie/meeting area. Ask, are you happy with this? Does this happen?

Ask – whose responsibility is it to address these problems? (Answer – every household in the community has the responsibility to maintain a healthy environment, otherwise the whole community can get sick).

Explain that you want to talk about different facilities that can be constructed by the households to maintain a healthy environment.

2. Waste Water

Ask participants what they do with waste water from cooking, cleaning, bathing your child?

Ask if there is a problem in throwing waste water on the ground around the compound, or having pooled water? (Encourage answers on flies, cockroaches on dirt from the wastewater, and mosquitoes breeding in pooled water).

Ask if there is any system or method that can help dispose of wastewater in a clean and hygienic way?

Explain that a soak away is an easy to construct method to help water soak into the ground and avoid pooling on the surface. It is basically a small pit filled to the surface with gravel/crushed/small stones. You can either throw waste water in directly, or like for wells, you can have a drainage channel leading to the soak pit.

Show the group the steps to constructing a soak away and the stones for filling it. Explain that it should be filled to the top with stones, to avoid people tripping into them.

Ask – where in the house should we have soak ways? Push for answers such as – underneath the tippy tap, close to the cooking/washing area, drainage and soak-away for the wells and handpumps.

Ask – where does the water go when we shower? Is it a problem? Explain that the floor of the shower could be a shallow soak away, digging down 10cm, and filling with small stones. Planting a banana tree next to the shower can use the water soaking away into the ground.

3. Solid Waste Management

Ask – do we generate solid waste in our homes? What types? Prompt for answers such as plastic sachets, food waste, and waste from processing food etc.

Show the flash card of pests, and ask – who are these? Are they are our friends, or a nuisance? What do they eat? Do they spread diseases? How?

Domestic Waste Management

Ask, how do we manage our waste in our homes? Where do we store it? Where do we take it after to dispose of?

Ask the participants to form 4 groups, and discuss what the current practices are for waste in their homes and community. Ask them to present the issues, or act them out.

Prompt for answers like:

cockroaches, flies and rats being attracted to the home to eat food scraps and spread disease

mosquitoes breeding in garbage and spreading malaria

open dumping around the community breeds rats that transmit diseases, and attract scavenging animals, and livestock can

Having a dirty community that brings shame when people visit.

Ask, where do we keep the waste that we generate in our homes? Is it attractive to pests? Can they access it? Show a sack/bag of food waste lying on the floor (e.g. their domestic bin). Ask volunteers to pretend to be cockroaches, rats and flies and walk into the bin and feast, and fly/travel to food etc.

Show the bucket with lid. Shake the waste in the bag into the plastic bucket, and put the lid back on. Show the volunteer (rat/cockroach/flies) cannot get in. Discuss.

Community Dump Sites

Ask, where do we take the bins once they are full? Are there any issues? Ask, are there specific/designated places for our waste? Do they protect us from rats and cockroaches in the community? How could they be made more sanitary? Discuss. Prompt/explain that sites should be ideally 50m or more from the nearest house (but not too far as people would not use it), avoid waterlogged areas, and would be a pit with a fence on it (to stop animals scavenging, and children from falling in). The pit should have steep sides so that rats cannot easily get in or out. The contents of the pit can be burned periodically, and can be used as compost for the fields.

4. Clothes Line

Ask – where do we dry our clothes? If we dry them on the floor, is it clean? Can we get sick from this?

Ask two volunteers to pretend to wash their clothes, one to lie the washing on the floor, one to hang up on the line. Lie some clothes on the floor. Ask participants to be dogs, rats etc., and walk over the clothes, urinating etc.

Explain that clothes lines can be used to dry the clothes and bedding, which helps avoid contamination from animal feces, worms and dirt. When bedding is aired it helps to avoid bed bugs, scabies and the spreading of skin diseases.

Ask –how many of us have one of these? Do you need to be rich to make one? Explain that they can be constructed using bamboo poles or string/wire. They should ideally be high enough to avoid contact with animals.

5. Pot Racks

Ask, what do you do with your plates and pots and cooking utensils after washing them? Where do you leave them to dry? Where do you store them?

Ask, what happens if you leave the dishes on the ground? Quick role-play – ask one person to pretend to wash the pots, and then leave them on the floor. Ask other participants to role-play what happens (e.g. one pretending to be a chicken, cockroach, one a dog etc. Ask, is the ground a clean place to put the pots?

Source: Moses/Tulane 2015

Ask, has anyone used a pot rack? Do we have these in the community? Show the example of the pot-rack, or the flash card of the pot rack. Ask, would it be good to use this? Why? Show the volunteer washing pots and putting them on the rack, and the animals not being able to get them.

Ask, if you made one of these, where would it ideally be located? What other features? Prompt for responses on the following:

site them close to the cooking area

make them high enough so that wandering animals cannot reach them

keep it clean by not putting dirty utensils, old rags, spoilt food etc. on it

periodically replace old worn out sticks and ropes

Key Messages

Keeping a clean house, compound and community helps prevent disease, and raises the dignity of the community

Every person and household has the responsibility to keep their house and community clean – bad practices in one house can risk the health of the whole community

Households can improve the hygiene by constructing pot racks, soak aways, managing and disposing of their waste properly, keeping the home clean, and using clothes lines

Action:

Each household should agree before the next session to do the following in their homes:

Construct a soak away

Dig a compost pit if there is not a community dump site

Put household waste in a covered, sealed container to prevent rats and other pests in the home

Construct a pot rack

Construct a clothes line

Explain what they learned today with other family members

As a club/community, they should:

Review where they take their waste, how it is dumped, and any improvements/by-laws needed for waste disposal

Look at areas of pooling water and construct drainage and/or soak ways

Session 16: Food Hygiene

Session Objectives

To understand the link between poor food hygiene and sickness

To understand how food can be contaminated at different stages (food source, preparation, eating, storage, re-heating)

To understand how to prevent food contamination at the different stages

Materials

The body map / large vanguard and marker

Tippy tap with soap or ash

Pot rack example

Flash cards

A chopping board

A knife

A communal family eating plate

A few spoons of palm oil

A bowl like those used in families to wash hands before eating

Some cooking pots

An example of raw fish and eggs

Example of food eaten raw from the fields – banana, mango, maize guava

Example of recently cooked food (e.g. a plate of rice and plassas)

A locally made fly net for covering food, and piece of lappa to cover a cooking pot

Examples of food storage containers – for uncooked and cooked food

Session Activities

1. Introduction

Hold up the body map vanguard. Ask, when we eat, where does the food go?

Ask, can we get sick from eating bad food? How? What happens? Ask a volunteer to pretend to have eaten bad food, and have stomach pains, diarrhoea etc.

Explain that you want to talk about food hygiene in today’s session.

Sourcing food Preperation EatingStoring

cooked foodRe-heating

Ask if people know what food hygiene means? Explain that it is about preparing, cooking and storing food in a clean way that prevents disease. Explain this starts with how clean the food is that you eat/cook with, how you prepare it, how you store it, and how you re-heat it.

2. Sourcing Raw Food and Ingredients

Ask, if we get food in the bush, like mango, guava… is it always clean? How may it be contaminated?

Skit – pretend to 2 men in the bush/farm, and act the following (talking if needed for the audience to understand what is happening). Use palm oil on the volunteer’s hands to demonstrate kaka.

One man (Mohamed) defecates under a mango tree, does not wash his hands (gets palm oil on his fingers), walks off

One man (Sam) is in the farm and needs the toilet, he defecates in the maize crops, and does not wash his hands. Then he walks off

The Mohamed and Sam meet together in the bush by coincidence. They shake hands, and both get kaka on their hands

The Mohamed goes walking and finds a guava. He picks it, gets palm oil kaka on it from his fingers, and then eats it.

Sam finds a mango on the floor under a mango tree, wipes it (does not wash it) and starts to eat it.

Mohamed goes to the maize/cassava farm and collects the maize/cassava, and brings it back home to cook with

Stop the skit, and ask participants to discuss what they have seen.

Ask, do we sometimes defecate in areas near to where our crops are (or upstream if it rains)? If this happens, what happens? Prompt for the answer, we are eating our own/our neighbour’s kaka.

Ask, how can we make sure the raw food we eat, and the cooking ingredients we get from the farm are clean? Prompt for answers including:

People should not defecate in the fields, as it will contaminate the food we eat

Any food to be eaten uncooked that cannot be peeled (like a banana) should be washed in clean water before eating

You should have clean hands if collecting food or eating in the bush

3. Food Preparation

Ask, when we prepare food, what are the different ways we could contaminate the food we eat? Collect the various answers.

Do a skit (or get a briefed volunteer to do it) showing bad practices, using the palm oil to show dirty hands. Practices could include:

Cleaning a child’s kaka, and visiting the toilet, and then preparing the food without handwashing

Preparing food on the ground on a dirty surface with animals around, using unclean pots and utensils

Using dirty water (e.g. from the stream) for washing/preparing the food

Stop the skit, and ask participants to say what they saw, and ask, is this happening in our community?

Discuss ideas on how to prevent contaminating food during preparation.

Prompt for answers to include:

Washing hands with soap and water before cooking

Using clean water to do any food preparation

Using clean pots, pans and utensils

Prepare food in a specific area, away from the ground (like a section of the pot rack or constructed kitchen area table), and clean surfaces thoroughly after use

Ask, is there some food that should not be eaten raw? Explain that some foods contain dangerous diseases (parasite eggs, bacteria) when they are raw. Examples include eggs, fish and meat. However by cooking them thoroughly (all the way through) at a hot temperature, these diseases are killed. Eggs, fish and meat should never be eaten raw.

Do a demonstration cutting raw meat on a surface with a knife. Put the meat in a pan, then wipe the knife on a rag/clothes (rather than washing it), and cut some pawpaw with the same knife and on the dirty surface. Offer a participant the pawpaw. Will they take it? Why not? Prompt to identify that the raw meat/fish contains bad bacteria, and knives, surfaces and hands should be properly washed before cutting other food, especially food to be eaten raw.

1. Eating

Ask, how do we normally eat cooked meals in this village and in our homes? Does this pose any risk for contamination? Allow some ideas, then start a skit with volunteers pretending to be a family. Use palm oil to simulate kaka on the hands. Acting the following:

Mother just washed the baby’s kaka, and has kaka on their hands

Father has been in town shaking people’s hands

One child has been crawling/playing on the ground (where there is animal kaka)

One child has just come from the toilet and not washed their hands

Mother calls that it is time to eat

The children competitively rush through ineffective handwashing (dipping their hands in the bowl carelessly, no soap..) to get to the food quickly

The mother and father also dip their hands in the same bowl carelessly, and then the whole family starts to eat together with their (palm oil) hands from one dish.

Stop the skit, and ask participants to discuss what they saw, and what could be done to improve the situation.

Answers could include:

Effective handwashing, using a tippy tap and soap/ash

A parent inspecting the hands of the children/family before eating

Emphasise that it is important that all family members have clean hands, as only one dirty hand can make the whole family sick

2. Food Storage

Ask, can food become contaminated after it is cooked? How?

Put some food on a plate on the table. Also put cooked food in a pot that is not properly covered, and place it on the ground. Do a skit including the following with volunteers:

Flies landing on food with kaka on their feet

Putting the food in a dirty container for storage

Not covering the food properly, so that flies, cockroaches, rats, dogs, chickens and other disease spreading pests can enter it and contaminate it

Ask – how can we store food in a way that it cannot be contaminated? Prompt answers regarding properly covering the stored food, and not leaving on the ground.

Demonstrate – fly contamination. Put palm oil on the floor to show kaka, and put a plate with bread/food. Ask a person to pretend to be a person defecating (over the palm oil). Ask another to be a fly, who puts their 5 fingers into the palm oil (simulating a flies feet on the kaka), then flies to the food, and puts their fingers (with the palm oil) onto the food.

Show examples of food storage containers, and the locally made fly cover. Emphasise to only use old/spare nets rather than cutting new ones for this.

3. Keeping and Reheating Food

Ask, when you cook the food and store it, can you keep it forever, or does it go bad? What happens if you eat food that is a bit old?

Ask what the current habits are regarding storing and reheating food, discuss briefly.

Explain that bacteria (germs) grow on food. Ask if the participants believe them? Have they ever seen them? Ask, have you ever seen mould grow on the food? What is this? Explain normally you cannot see it, but it is there.

Explain that germs (bacteria) start to grow on the food, and can make the food bad to eat, and make you very sick. The bacteria grows on cooked food, especially in the nice warm and moist temperature like Sierra Leone.

Cooked food should be stored in a cool place (e.g. out of the sun), as the germs breed quicker in the heat. Cooked food should be eaten while hot, and if not stored properly away from flies etc. and eaten soon.

Food that has been stored, especially if it contains meat, eggs or fish, should be reheated very thoroughly (boiling) before eating, as harmful germs breed on cooked meat, and can only be killed if heated very hot (not only warmed).

4. Food in the Market and Food Sellers

Ask, do you think there are ways that the food we buy, from the market, and from the food sellers /hawkers can be contaminated by their bad hygiene? Prompt for examples such as; not covering their

Source: WHO Healthy Villages Manual

fish/food from flies; selling food on the ground; not washing their hands. Ask – are they putting our health at risk? Should you tell them how to improve their practices?

Key Messages

Food hygiene is very important to keep you and your family healthy

All raw foods that cannot be peeled should be washed before eating

Wash your hands before cooking and eating, and use clean water, utensils and pots

Cook food thoroughly to make sure it is safe to eat, especially eggs, fish and meat

Store food away from flies and other pests to avoid contamination

Food should be re-heated thoroughly before eating to kill germs, and thrown out if gone bad

Action

Spread the messages learned to other members of the family and community

Make up a song about food hygiene

Consider getting assigning one person per family to be the ‘hand inspector’ to check hands are clean before eating together

Talk to the community about addressing bad hygiene practices of those selling food at the market/ door to door

Make, find or buy items to properly store food away from flies and other animals

Module 7: Key Communicable Diseases

Session: 17 Diarrhoea

Session Objectives

To understand/recognize the signs and symptoms of diarrhea

To understand how to treat diarrhea and when to refer cases to CHWS and to health facilities

To understand what causes diarrhea, and ways to prevent it

Materials

copies of a picture of a healthy baby (need multiple copies for the groups)

pencils/markers

sheets of paper (enough for one per club member to draw the sugar-salt solution picture for their homes, plus to draw a few ‘healthy baby’ pictures)

1 water storage container (jerry can or bucket with lid and tap)

1 large cup

An ORS sachet (if available)

Sugar & iodized salt 1 cup each

tea spoon

1 pin

A few small (ideally clear) plastic bag with a baby drawn on it (if absent could use empty water sachet

A tooth pick/other sharp item to puncture a small hole in the bag

Charcoal/chalk to draw lines on the F-Diagram

Tippy tap

soap/ash

Flash cards (F diagram, ORS preparation, and others listed below)

Session Activities

1. Introduction

Ask, does anyone have or know of a baby that has had diarrhea (run-belly) that lasted for over a day?

Ask participants to turn to the person sitting next to them and for a few minutes exchange experiences with babies with diarrhea. If they don’t have babies, they can talk about an experience with adult with prolonged diarrhea.

Ask, is this condition (diarrhea) common in the community? Is diarrhea a problem?

Ask a couple of volunteers to briefly explain their experience with a baby that had prolonged diarrhea, and what they did to handle the situation/what happened.

Explain that this session will look at diarrhea generally, and especially in young children, that is when a baby or small child has had watery stools 3 or more times in a day, with or without vomiting.

Explain that diarrhea is particularly severe in children who are malnourished; remind participants that such a child’s immune system is weak and the child is therefore vulnerable to all diseases, especially diarrhea.

2. Symptoms of severe diarrhea

Ask participants to get into groups of about 5, and give them a piece of paper and crayon/marker. Show the ‘healthy baby’ flash card, and ask them to copy it. Ask each group to mark on their picture what changes you can see on the body when a baby or small child has had severe diarrhea for a few days.

Ask each group to present one sign or symptom and discuss it, then another and so forth.

Responses could include the following:

sunken eyes

sudden weight loss

inelastic skin (pinch test)

dry lips

little or no urine; the urine has a dark yellow color

no tears

cool / clammy skin

It can also include:

abdominal discomfort

excessive weakness

poor / no appetite

cannot take water orally

dizziness

vomiting

3. Traditional Practices for Diarrhea

Ask participants to discuss briefly about traditional practices for if a child or baby has diarrhea.

Ask, do you give more or less breastmilk? Do you give more or less food or water?

4. Dehydration & Rehydration

Explain that many of these symptoms are due to dehydration – what happens when you have lost too much fluid from inside.

Source: www.nationwidechildrens.org

Demonstrate what happens to the body when it loses fluids:

Fill the plastic bag with water and explain how the plastic is stretched and smooth, just like a child’s skin. Pierce a hole into the bag and show how, as the water runs out, the plastic becomes less smooth and stretched until it is wrinkled and empty.

Explain how the sunken eyes and fontanelle on a baby are just like a dent in the plastic bag – they show there is not enough water in the body.

Ask, if a baby is dehydrated, can the soft part of the middle of the skull (the fontanelle) be sunken>? Explain that a sunken fontanelle shows that a baby is very sick, and will die soon unless quick action is taken.

Explain you can also pinch the child’s skin. If you pinch it and it goes down slowly, it is a sign of dehydration.

Ask – if someone is dehydrated, are they likely to keep urinating (pissing)? Explain that as they have less fluids inside them, they may continue to have diarrhea, but they stop urinating.

Ask, how much fluids do we need to replace? Answer, you need to replace what is lost, so anything you lose, you need to add (e.g. top-up ORS as long as they are losing fluids.

5. Oral Rehydration Therapy

Explain that when you have diarrhea, you lose lots of fluids and nutrients. If these are not replaced, then they may die.

Ask, how can you replace the fluids and nutrients for a child that is exclusively breastfed?

The correct answer is that the child should be breastfed more frequently. No fluids aside from breast milk should be given to a child that is exclusively breastfed. The mother must continue to feed the baby breast milk only, as often as the baby will take. If they are not taking on milk, they should be taken urgently to a health facility for a drip.

Source: www.fastonline.org

Source: www.nzdl.org

Source: www.en.hesperian.org

Explain that when a person is losing fluids through diarrhea, they lose fluids, salts and sugars which are essential to keep our body working. Explain these fluids and nutrients are available in breastmilk for babies, but need to be made for children and adults.

Ask, how can you replace fluids for a child over 6 months, or in an adult?

The correct answer is through oral rehydration.

Ask if anyone knows what ORS is, and how it is made? Ask a volunteer to demonstrate preparing it, talking the participants through the key steps:

Measure 1 clean cup of safe water + 3 level teaspoons sugar + a little salt at the end of a spoon. Explain that the water used must be clean, ideally boiled. The resulting mixture should taste like tears.

Ask if there are alternatives to ORS? Explain that some people use (and show examples if you have them):

Young coconut (jelly) water

rice water

Coke or Fanta that has been left to stand so that the bubbles are no longer there

Ready-made sachets of ORS

Dosage of ORS

Ask, how often should you give the ORS to a person with diarrhea? Outline the treatment:

explain that a child should have 1 cup of ORS for every watery stool

give the ORS in small sips from a cup, or with a clean spoon from a cup

continue to give the child the ORS all day and all night until the diarrhea stops

if the child vomits, stop for a few minutes to give her/him time to recover, and then continue giving the solution

keep giving food as often as the child wants it and continue to breastfeed (if they are breastfeeding)

6. Referring to the CHW and Health Centre

Ask, should we report diarrhea cases to the CHWs?

Explain that all cases of diarrhea should be reported to the CHWs, so they can monitor disease incidence in their community, and they may be able to give drugs such as zinc and ORS. They can also refer more acute cases to the clinic for treatment.

7. Causes and Prevention of Diarrhea – the F Diagram

Ask, why do people and especially children get diarrhea? What are the causes of diarrhea?

Prompt for answers that diarrhea comes from sickness passed from one infected person’s gut, to another person’s mouth (remind participants of the F diagram covered in the total sanitation session).

Explain that you want to recap on the different ways that sickness can pass from one person’s belly, and get into another person.

Lie out the F diagram flash cards on the ground (as was done in total sanitation), in the order shown below. Ask participants to identify what they are as you are placing them down, so everyone understands what they represent.

Then take charcoal/chalk and draw the connecting arrows between them as shown on the F diagram above, explaining that the different lines represent the link/path/road between the different steps.

Ask participants to explain/remember the different routes, by giving visual acting.

Then ask for examples of how the pathways can be broken, e.g. by toilet use (with cover), covering food, covering feces, using clean water, washing food etc. Mark the breaks in route with the charcoal, as shown in the diagram below. Act out the ways where possible.

Explain that to prevent diarrhea and many other diseases, all community and household members must take steps to break the pathways, by good sanitation and hygiene, and using safe water sources.

Key Messages

Diarrhea over a period of time is dangerous, and needs to be treated by rehydration

Babies exclusively breastfeeding should be breastfed more regularly, as often as they will take it

Children and adults should receive oral rehydration therapy

All cases of moderate to acute diarrhea should be reported to the CHW, and severe diarrhea may require treatment at the health facility

Image adapted from sswm.info

Adapted from image sourced on www.nzdl.org

Prevention is better than cure. Good hygiene practices such as handwashing and toilet use can prevent diarrhea.

Action

Each CHC members should have a Sugar-Salt Solution picture displayed in their homes. Get them to draw them at the end of the session with the paper and markers.

All cases of diarrhea should be reported quickly to the CHW

The members should tell other family and community members what they learned

The members should make up a song about detecting and treating diarrhea

Session 18: Intestinal Worms

Session Objectives

To raise awareness about the signs, causes and transmission of common worms

To understand the effect of worms on the body

To identify ways of treating and preventing worm infestation

Material

Markers

Slippers

Flash cards (F diagram, body map, and others listed below)

Session Activity

1. Introduction

Ask, does anyone know what intestinal worms are? If so, what are they, and what effects do they have? Show the flash card with worms.

Ask if people think this is a common problem in this community?

Ask, where do you think they live inside us? Show the flash card of the body map and ask them to point to it.

Then agree that they live in the gut, eating the food we eat and sucking our blood from the lining of the gut. Show the second body map flash card with the worms shown.

2. Signs and Symptoms

Ask what are the signs and symptoms of having worms? Ask participants to act them out.

Probe for answers such as:

Itchy anus, loss of appetite, loss of energy

Swollen, shiny belly

A cough, without other cold symptoms

Pain in the belly

Worms seen in feces or coughed up phlegm

Nausea or vomiting after meals

Children may be pale and display signs of anemia

Children may also have odema (swelling) of the face and feet and loss of weight.

Children may develop a fever, an itchy rash and a swelling between the toes which is sometimes called a ‘ground itch’.

Adapted from Care manual and www.guardianrottweilers.com

Sources: www.fao.org; www.yourarticlelibrary.com

Ask, what effect do worms have on children? Probe for answers such as the following:

They become malnourished and anemic, which stops them from growing up healthy and strong

Explain that worms are a very common problem for small children. Sometimes worm infestation can get so bad that the child becomes ill. Yet, worms are treated easily and infections can be prevented. This session looks at roundworms and hookworms.

3. Transmission from person to person

Ask – how do you can catch these worms?

Ask, how do the worms leave us and infect someone else? Explain that the worms and eggs of the worms pass out of our gut in our shit.

Ask, how can it be transmitted to another person?

Explain there are two main ways –one from shit into the mouth (the F-Diagram). The other way is getting them in through the feet.

Fecal-Oral

First, run through the shit to mouth way by laying out the F-diagram cards on the floor and drawing the F-diagram (like was done for the diarrhea session). Ask people to show their ideas. Also show the itching anus flash card to prompt ideas around hand to hand transmission.

Soil-Feet-Lungs-Gut

Explain the second method by lying the following flash cards on the ground in order, and explaining the process. Ask three volunteers to demonstrate as you speak.

Images sourced from Care Manual, www.wawash.fiu.edu adapted from www.guardianrottweilers.org, www.healthyblackmen.org www.nzdl.org

First volunteer that has stomach ache/worm symptoms defecates on the floor, and walks off

The eggs and worms go into the soil. They can live there a long time, long after the shit has gone

Second volunteer walking in the area with no shoes/slippers on walks on the soil with no soil. The worms burrow into the foot (they are small, and you can’t see them)

The worms go to the lungs

They make you cough, and they are coughed into the mouth

You swallow your spit, and the worms travel to your belly

Adapted from image sourced on www.nzdl.org

The worms breed in your belly and suck your blood and eat your food

The second (infected) volunteer defecates the eggs and worms, and walks off

The third volunteer walks in the area with no shoes…

Explain that the eggs and worms are in the spit of people who cough, so people should not spit where children are crawling.

4. The story of Aminata

Ask for 5 volunteers to act out a pre-rehearsed drama. Brief them before the session. This includes:

Aminata

Mother

Mariama (the CHW)

Sorie – Aminata’s young brother

Tell a story with gaps with the volunteers acting:

Aminata was a bright child and very energetic. On her way back from school she found a mango lying under the tree and she picked it up without washing and started eating it. A few days ago, Aminata was sitting at the front of the house very quietly, coughing a little, and her mother saw she asked her “Aminata what is wrong with you? Do you have malaria? And she replied that she didn’t feel that way. Do you have a cold? She replied that her nose was not running.

But a few minutes ago, her mother standing from a distance saw Aminata crying of stomach ache, clearing her throat and at same time coughing. During the process, Aminata’s friend (Mariama) who happened to be a CHW came to visit her at home and her mother explained Aminata’s issues to her. Mariama asked Aminata “what is wrong with you”? Aminata replied that a few day ago on her way from school she pick a mango laying under the tree and she ate it and she has been feeling very uncomfortable since this happened. Her mother asked her “did you wash the mango before you eat it?”, and Aminata bowed down her head guiltily, and said “no”.

The CHW asked “Aminata, are you tired?” She replied “Yes”. “Is your stomach aching?” “Yes”. “Do you feel nauseous after eating or not want food?” “Yes”. “Have you had a cough?” Yes”. Mariama conclude that she has been affected with worms. Her mother asked her “Where are your slippers?” “You see this is one of the ways you get this worms in your stomach because you always walk on foot without slippers”.

Marima explained the Aminata that she had worms that were inside her belly, and also in her lungs that she was coughing up.

Aminata did not like the story of worms. She thought it was horrible that there were baby worms in her lungs, and worms sucking blood in her gut, and they were making her tired and weak, and that every time she had eaten she felt a little sick. So she asked her mother to give her something to get rid of the worms.

5. Treatment

Ask: What advice would you give someone to treat the worms?

Probe for local home remedies, such as pawpaw etc.

Ask, is there medicine you can take?

Return to the story of Aminata:

Aminata’s mother asked “Mariama, what am I going to do? Shall I give her pawpaw or take her to PHU center?” And Mariama the CHW provided an abendazole tablet to her, explaining how he should take it and said if she became worst she should take her to the health facility.

6. Prevention

When they got back from seeing Mariama and taking the medicine, Aminata’s mother called all her children. Talking to the CHW she had learned more about worms and she was worried that her other children might be infective with them too. First she called little Sorie and said: ‘are you itchy my son I have noticed that you scratch your anus a lot, especially when you wake up in the morning, and after you have been to the toilet. Show me your hands!’ She saw that his fingernails were quite long and dirty and told him she would cut them short. She also decided she would wash all the bedclothes. ‘We are going to get rid of all the worms in this house!’ she decided, and so she gave all the children a little lesson on how to prevent worms.

Ask – what advice would you give about the prevention of worms? Prompt for answers such as:

Use a toilet rather than defecating in the bush, and if defecating in the bush bury the feces

Wear shoes/slippers especially in the toilet/bush

Keep your compound clean and free from feces, and ensure your small children play in a clean place

Wash your hands after defecating and before cooking/eating

Cut your fingernails short and keep them clean

Drink only clean water

Do not spit on the ground where children play

Key Messages

Worms are common in the communities, and lead to reduced growth and strength of our children. They should be prevented and treated.

Worms can be prevented by wearing shoes, handwashing, using toilets, drinking clean water and good food hygiene

Worms can be treated by visiting your CHW for medicine.

Action

Check all family members for signs and symptoms of worms, and refer to treatment to the CHW if found

Cut all family members nails and clean with a brush

Make up a song on worms, their transmission and prevention

Session 19: Malaria

Session Objectives

To understand what Malaria is, and recognize it’s symptoms

To understand how it is transmitted from human to human

To understand how to prevent transmission

To understand how to treat Malaria

Materials

ITN (Insecticide treated net)

Locally used insecticides (including cow dung, orange peel etc.)

pieces of fabric / “lappa” to cover up at night

Bucket of water and lid

The soak away from the previous domestic hygiene session

Dried orange peel

A cigarette lighter or matches

wire mesh window frame

A Hoe

Flash Cards Malaria life cycle

Session Activities

1. Introduction, Symptoms of Malaria

Ask, has anyone here ever suffered from malaria? How did you feel, what were the symptoms?

Ask a volunteer to demonstrate/act the symptoms as people call them out.

Prompt for answers to include:

severe headaches and aching joints

a fever attack, in 3 stages:

o cold: the temperature rises but the person feels cold and shivers

o hot: for 3-4 hours the temperature is very high (40 degrees C), the skin is dry and hot, there is severe headache and often nausea and vomiting

o Sweating: the temperature falls rapidly for 2-4 hours. The patient feels better but sweats profusely so that the bed clothes are soaked.

loss of appetite

sometimes diarrhea

dizziness

weakness

Ask, are there some people that are more vulnerable to getting very sick from malaria? Explain that pregnant women, children under 5, and sick and old people can get really sick if they get Malaria.

2. Causes of Malaria

ASK: Why do we get malaria? Where does it come from?

Collect all the suggestions made by participants. Probe beliefs and myths: what evidence do people use for this belief? Where does the belief come from? Explain that associations with mangos, drinking places (bars) etc. have to do with places where mosquitoes breed or with people’s behavior at night. They are NOT causes of malaria.

Explain that mosquitoes are the sole cause of malaria.

3. Malaria cycle

Ask for 6 volunteers. Distribute malaria cycle cards. Ask each one to describe her / his picture.

Ask the six to stand in the order of the cycle and help them to tell the story of the malaria cycle (the sequence above is the correct order).

Ask a volunteer to act to be a mosquito, and one to be the sick man. Ask another to be a malaria parasite (like a small worm that lives in the blood), who starts off swimming around in the sick man’s blood. Ask another volunteer to be the woman. They then act as you read the following.

Mosquitoes lay eggs into standing/stagnant water, such as rain water puddles, streams, banana trees, coconut shells, foot marks of cows, garbage, pooled waste water etc.

In one week the eggs hatch into larvae (like tiny worms in the water). New adult mosquitoes emerge from these, and fly out of the water to find an animal or human to drink their blood

The man is sick with malaria. It is caused by tiny malaria parasites (like tiny worms that you can’t see as they are so small) in his blood. They make him sick with fever and make him weak. Show the parasite volunteer pretending to swim around in the sick person’s body.

When the mosquito bites the sick man it drinks his blood, including the malaria parasites. The parasite is now in the mouth (spit) of the mosquito. Show the parasite volunteer getting onto the back of/holding onto the mosquito volunteer

When the same mosquito bites the woman, the parasite in its spit enters the woman. This is how she gets the parasites into her blood. Show the mosquito and parasite moving to the healthy woman, the mosquito bites her, and the parasite then pretends to move into the body of the woman.

The malaria parasite invades the blood of the woman, and grows and multiplies It will take about 10 days for the person to show the symptoms of malaria. Show the woman getting sick with malaria (e.g. fever).

4. Prevention of malaria

Explain that this cycle can be stopped: malaria can be prevented.

Gather the props listed under ‘materials’, including other locally used anti-mosquito devices. Ask the volunteer playing the mosquito to come back and keep acting.

Explain that we will now have a demonstration of what we can do to stop malaria.

Lie out the malaria cycle cards on the floor, and ask participants to come forward to point to a particular card, and say how they think it can be prevented. The volunteers act out their suggestions. Prompt for answers such as the following:

Fill in potholes where rainwater collects and stands. Demonstrate using the hoe to fill in potholes. ‘Mosquito’ flies around and around the hole and leaves.

Construct soak ways to prevent pooled water from the bathroom/kitchen waste water. Visit a local household soak away if appropriate, or pretend to pour water into a soak away. The ‘Mosquito’ flies around and around the soak away and leaves.

Dig community drainage channels through the community

Cover up water containers. Act covering up containers. ‘Mosquito’ bumps into container and has no access, and leaves.

Clean up garbage such as tin cans and plastic bags where water can collect. Mime picking up garbage and plastic bags and putting it away. Mosquito flies off

Pause, and ask the community to think/look around and see if there are things that need to be done in their community?

Continue on how to prevent malaria

Put Insecticide Treated Net (ITN) over a ‘healthy’ person. ‘Mosquito’ buzzes around the net but cannot reach her/him.

Cover-up in the evening before bed - Healthy person puts a lappa around her/his shoulders. Mosquito cannot get to her/him.

Spray or burn repellent around the infected and healthy persons (e.g. burn the dried orange peel). ‘Mosquito’ pulls a face and flies away.

Put wire mesh on windows of houses and/or close the windows (e.g. from dusk to around 8am). Hold up a mesh frame; ‘Mosquito’ flies and bumps into it – and then turns away.

5. Insecticide Treated Bed Nets (ITN)

Ask, who in your household has an ITN? What happens to other members of the household who do not sleep under an ITN? What do you do if the husband wants the ITN wherever he sleeps?

Have a short discussion around insecticide treated nets (ITNs) and who should sleep under them.

Then explain the following:

Pregnant women, babies and children under five years are particularly vulnerable to malaria.

Pregnant women qualify for a free ITN which they can get at the local health center.

Ask, where can you buy bed nets for the other family members (aside from the pregnant women/children<5 yrs. who often get them free)? How much do they cost? Do you think the cost is less than the cost over the years of being sick with malaria?

6. Treatment of malaria

Ask, what do you do when someone has malaria? How can it be cured?

Ask, who do you go to if you or your family member has malaria? The traditional healer? The quack? The market to buy your own drugs? The CHW? The health facility?

Take a few minutes to discuss different treatment options and practices.

Explain the following:

Report any incidence of suspected malaria to the CHW for treatment or referral where necessary

In case the situation becomes worse, take the sick person to the hospital or health center for a blood test and treatment

Proper treatment as soon as the first symptoms appear is important. People are generally given a drug called ACT, which is given free

Pregnant women may need to take a different drug – advice is available at the local health center

Medications must be taken immediately, and to finish the whole treatment course. If the person continues to be sick s/he must be taken back to the health center or hospital

Key messages

The malaria parasite needs the mosquito to spread from one human to another.

Mosquito bites can be prevented by using an Insecticide Treated Bed Net (ITN), covering up, using/burning repellents, closing windows or using mesh on the windows, preventing breeding sites through avoiding pooled water.

Everyone in the family should sleep under a bed net, especially pregnant women and babies/young children

Immediate action when malaria is suspected saves lives

Wear clothes that cover most of the body – long sleeved shirts and trousers in the evenings.

Get free ITNs for pregnant women and children under 5 years at the local health center.

When under 5 year olds get a fever they must be taken to the CHWs/health center

Action

Each household to check for mosquito breeding places.

Establish village environmental sanitation days for general clean up and drainage.

Each household to acquire ITNs, especially for pregnant women and children

Session 20: Acute respiratory infections (ARIs)

Session Objectives

To understand the symptoms, transmission and prevention of common colds, and ARIs such as pneumonia ARIs

To understand the treatment for common colds and ARIs such as pneumonia

Materials

2 small bowls of boiled water

1 teaspoon of salt

A cup

a paper handkerchief/tissue

A small plastic bag/used water sachet to demonstrate the lung filling/deflating

Flash cards – body map, baby breathing, sneezing

Session Activities

1. Introduction: Myths and facts about common colds

Ask – Who here has ever had a cold / runny nose?

Does this happen often? Do you often have a cold?

Where does it come from? Why do you get it?

What did you do about it?

Do not respond to any of the experiences and views.

Explain that you will now make many statements about colds – some of these are true, and some are not. If participants think you speak the truth, they should stand up – if they think your statement is not true, they should remain seated. After each statement ask one of the people standing sitting to explain why they believe the statement to be true /untrue. Begin:

You catch a cold from getting wet feet. (untrue: old myth)

You catch a cold from somebody sneezing close to you. (True: colds are transmitted from others who are infected with the virus. A sick person should cover mouth and nose when s/he coughs or sneezes)

You catch a cold because there is a lot of pollen from flowers and grasses in the air. (Partially true: the pollen may cause an allergic reaction that makes you sneeze)

You catch a cold from sleeping next to somebody who has a cold. (True: the virus can be transmitted through the air. A sick person should eat and sleep separately from the other people in the household)

When you have a cold, you must get near the smoke of a fire. (untrue: you need clean, non-smoky air)

When you have a cold, you must get near a bucket of steaming water with a sheet or blanket over your head. (true: breathing in water vapors helps to loosen mucus)

When you have a cold, you should not drink water because it makes your nose runnier. (Untrue: you should drink plenty of water to loosen the mucus.)

NOTE:

The experiences and knowledge questions at the beginning should have raised some truths and untruths myths and facts – raise them in the ‘true / untrue’ exercise for discussion and decision. Ensure participants are clear about what is untrue!

2. Transmissions of Respiratory Infections

Explain that colds are an infection from germs that get into your nose and throat.

Show the body map flash card. Ask participants to point to the map and identify the nose, nasal, cavity, throat, windpipe, and lungs (no need to cover the digestive system of stomach, intestine etc.).

Ask, when we have a cold/sore throat, where does this affect? Ask participants to mark on the map (it should affect the nasal cavity and throat).

Ask, how can infections pass from one person to another?

Ask a person to pretend to sneeze. Ask what happens? Ask a person to blow their nose. What happens?

Show the sneezing flash card. Explain that germs that are in the throat, nose or lungs leave our body when we sneeze, or blow our nose.

Ask, what are the different ways that an infection can pass from a person to another person?

Skit – practice this before the presentation with the 5 volunteers. The volunteers are playing the roles of a family – father, mother, and three children.

The skit does as follows:

Father has a cold – runny nose and sneezing. During the family meal the father is talking to the mother and then sneezes at her without covering his mouth.

The mother now has a cold. She sneezes on her hand, and then shakes the hands of the oldest child.

The oldest child now has a cold, and shares the same bed with the middle child.

The middle child now has a cold. The mother asks the middle child to blow their nose into a rag or handkerchief, then uses the same handkerchief/rag to wipe the face of the youngest child. The youngest child now has the cold.

Ask participants to explain what happened and the various ways infections like colds can be spread. Prompt for answers including the following:

A person sneezes in the air, and does not cover their mouth/nose. It gets into the air and someone else inhales it. Ask – is it more likely to inhale it if you are close to the person (like sharing a bed), or in a place with poor ventilation (like a crowded room with no windows open)

A person sneezes onto their hands, then shakes other’s hands/feeds baby/prepares food etc., and it gets into the next person’s mouth

Sources: www.forums.catholic.com; www.open.edu

A person blows their nose/wipes the nose of a baby and does not wash their hands

A person shares a handkerchief/rag with another person (e.g. a mother using the same cloth to clean two children’s nose)

3. Prevention of Respiratory Infections

Ask, what are the ways we can prevent infections passing from person to person?

Show the sneezing flash card again.

Ask 3 volunteers to stand, and act out the 3 ways of sneezing – into the air, into the hand, into the elbow.

Ask, which one is better to prevent disease? Is it good to sneeze onto your hands? Is it good to sneeze into the air? Do we touch people and food with our elbow?

Ask all participants to stand up, and practice sneezing into their elbow 5 times. If there are observers/children in the session, encourage them to also do it.

Ask, are there other ways to prevent the spread of colds?

Explain/prompt for answers on the following:

Handwashing is a key way to prevent ARIs. Ask, when should we wash them?

Sick people should not sleep in the same bed as a healthy person, and should try to avoid contact where possible with healthy people to stop them from infecting them

Keeping the house well ventilated (but with mosquito mesh on windows to avoid too many mosquitos)

Mothers, wash your hands and think about the cleanliness of the rag when clearing snot from the babies/children’s nose

4. Treatment of colds

Ask, what can we do to treat a cold?

Collect suggestions of home remedies/ideas. Prompt for suggestions to include:

Eat lots of fruit, especially oranges and tomatoes because they have lots of Vitamin C· Have plenty of rest.

Make a salt-water mixture from 1 cup of water and 1 teaspoon of salt. Gargle with the solution to clean the back of the throat.

Hot water in a bowl (possibly including eucalyptus) and putting a towel over the head and inhaling the steam (“Chinese steam”)

Pneumonia

Explain that some colds and infections can get serious.

Ask, do you know any babies that have had pneumonia before? Ask, what was it like? What happened?

Source: www.avoidtheoutbreak.worldpress.com

Explain that serious infections of the respiratory system, especially when the infection gets into the lungs, is a major cause of death in children. Explain that babies, small children and people with weakened immune systems (e.g. old people or those with HIV/AIDS) are particularly at risk of pneumonia.

Show the body map showing the respiratory system. Ask someone to point to the lungs. Explain/demonstrate how when you breathe in, air goes through your nose and mouth, down the wind pipe, and into the lungs. Ask all participants to take a deep breath in, noticing how their chest rises and falls. Explain that lungs are like bags that fill with air as you breathe in and out. We need this air to live.

Take a used water sachet or small plastic bag and blow into it to inflate it, then such it out, showing how a lung works.

Point to the body map, and explain how pneumonia is an infection that passes through the nose or mouth, down the wind pipe, and into the lungs. It causes an infection in the lower lungs that stop them working properly. They can fill a little with mucus stopping air getting in to all areas of the lungs, and making it hard to breathe.

Take the bag again, and pinch down/tie a knot in the lower corner to demonstrate the lower lung not working properly. Then blow air into it, showing that not so much air can get in. Ask, if you had pneumonia, would you have to breathe more often to get the amount of air you need?

Ask, what are the symptoms of pneumonia?

Fast breathing

Fast, shallow breathing. This is because the lungs are not fully working. This fast shallow breathing would be more than 50 breaths per minute in a child under 1 year, and more than 40 breaths per minute in a child aged 1-5 years. Stop for a minute, ask someone to time a minute, and ask participants to count how many breaths they/their baby takes.

Breathing in the lower chest

In a baby/young child, the lower part of the chest goes in as the child breathes. Show the flash card of the baby. Ask mothers to show their babies to the participants. Explain where their normal chest movement is, and what it would look like if the child had pneumonia.

Other symptoms include:

sometimes difficulty or painful breathing, sometimes wheezing, sometimes grunting when exhaling

The persons nostrils often spreads with each breath

fever

the person looks very ill

cough (often with yellow, greenish, rust-colored or slightly bloody mucus) with fast breathing

chest pain (sometimes)

A child often refuses to drink anything (therefore you must check for dehydration!)

Source: www.medicalobserverph.com

Ask, how can you prevent Pneumonia?

Ask, if the home where the baby stays is smoky from the fire or because family members smoke, will their lungs be healthy? Answer is no, people need clean air to have healthy lungs.

Explain that houses should be well ventilated to have fresh air in the house. Babies/young children should not be in smoky places if possible.

Treatment of pneumonia

Explain that sometimes a cold can turn into pneumonia which can threaten a person’s life especially if the sick person is a child. Pneumonia needs immediate treatment.

Ask, what do you do if you think a person has pneumonia?

Explain that they should be taken to the CHW/health center urgently, as they need treatment!

Explain that most cases can be treated with a specific type of antibiotics that the CHW/health facility can provide. In some cases, the patient may need further treatment.

Additional advice includes:

give paracetamol to bring down the fever and deal with pain

Give plenty of liquids. If the sick person does not want to eat, give liquid foods such as soup or porridge

if the person has a bad cough have her/him breathe hot water vapors

continue breastfeeding, if the sick person is a breastfed child

Key messages

Respiratory infections infect your nose, throat and lungs. They can be prevented by:

o Handwashing, and being hygienic with cleaning babies/children’s noses

o Sneezing always into the elbow

o Isolating infected people (e.g. they sleep in a separate bed)

o Ventilation in the home

o Healthy living and eating – eating fruit and vegetables, not getting too tired etc.

Pneumonia is a serious infection, and needs to be monitored in children, and referred and treated urgently

Action

Make up a song that teaches people what to do when they have a cold, and how to prevent it by sneezing into the elbow

Make up a bylaw in the club/community about sneezing into the elbow

Check your children for signs of pneumonia, and teach them about how to prevent infections

Session 21: Lassa fever

Session Objectives

To understand what Lassa Fever is, what it’s symptoms are, and the need for medical treatment

To understand how Lassa Fever is transmitted, and how to prevent it though personal, domestic and community hygiene and sanitation

To understand how to control rat populations in the home and community

Materials

A common (bad) local food storage container

A covered plastic food storage container with lid (50-100l bucket with lid)

Local examples of food storage containers from inside the community (e.g. wooden box, metal trunk...)

An open container/box without cover with various dried/uncooked food items in it (e.g. Maggi, vegetables etc.)

An open bag of rice from inside the community

A locally used (bad) water storage container with no lid

A bucket with a lid and bailer

A 5 gallon yellow jerry can with lid

A locally used domestic waste bin bag (bad) with no lid, and food scraps inside

A covered plastic bucket with lid for domestic food waste

A plate of food

A plastic bowl and cover to put the plate of cooked food inside

A pretend rat for the rat trap

A locally made rat trap

A manufactured metal snap rat trap

A spade (to dig and bury the rat)

5 plastic bags (to show how they can be used as gloves)

Flash cards showing rodent and feces, rat traps extermination devices, handling of dead rat

Session Activities

1. Introduction

Ask, has anyone ever heard of Lassa Fever? What is it? Is it real? What causes it? Is it dangerous?

Allow a short discussion between the participants.

Ask, are rats clean? Do you think they have diseases that we may catch if we come into contact with them or their shit?

2. Signs & Symptoms of Lassa

Ask what are the symptoms of people with Lassa Fever? Ask a person to act them out as they are being called out.

Fever

Body pain

Fatigue

Sore throat

Vomiting

Diarrhea

In severe cases, symptoms can include:

Hemorrhaging or bleeding

Explain that Lassa Fever is a very dangerous disease, transmitted to people by rats. Explain that Eastern Sierra Leone has the highest number of cases per population in the world.

3. Transmission of Lassa

Show the flash card of the type of rat, and ask, do we have this type of rat in our houses and communities?

Explain that Lassa Fever is transmitted by a rat which is very common in Sierra Leone, generally living in or close to rural communities. The virus is in their blood, and also in their urine and shit/droppings. The virus is transmitted to humans when humans come into contact with the rat’s blood, urine or droppings.

Ask, how can this happen? Get different responses from the participants, asking them to act out what they are saying for the group.

Answers could include:

Rat shit or urine on the floor/surfaces, people touch this and then don’t wash their hands before eating/feeding children

Rats eating stored food and shitting/urinating on it, and we eat the food, or shitting/urinating on plates or spoons

Rats urinating in our water sources (or near it and then it getting into the sources during the rain), rats urinating in our domestic stored water

Catching rats to eat

Ask, are there rats in our communities and homes? Why? What do they want? What are they attracted to?

Ask participants to imagine for a minute that they are a rat in the bush. What is attracting them to come to the community and our homes?

Skit – rehearse it before the session with 3 volunteers.

Source: Moses/Tulane 2015; www.squirrel-attic.com

Ask the 3 volunteers to stand up and pretend to be a family of rats, living in the bush, and they walk past the community. Ask them to do a role play talking to each other about moving into the village, walking around looking at all the places they can eat, drink and sleep. Start at the dump, then walking between the streets, then in the houses. Prompt for items such as:

Food in the dump site

Food in garbage thrown around the community, and water in pooled water/garbage

Stored water and food in the house

Shelter in the house, entering through holes in the wall and cracks under the door etc.

Role play the rats eating, drinking, shitting and urinating as they move around.

4. Lassa Fever Prevention

Ask, how can we prevent Lassa Fever?

Ask, where do we dump our garbage? Does it have food for rats? Is it easily accessible for rats? Explain that food waste should be put in designated community dump sites, located at least 50m from houses). Explain that the type of rats that transmit Lassa are not good at climbing, so a waste pit that has steep sides can help prevent them from entering/exiting.

Ask, do we have food waste or food for the rats in the streets/between the houses of our community? Do we have waste water pooled for them to drink? Explain that food waste should be put in the dump site and not on the streets. Waste water/stagnant pools should be drained or filled up.

Ask, do we have food inside the house that the rats will be attracted into our home for? Is it accessible to the rats? How do we store our food? How do we store our water?

Demonstrate:

Ask a volunteer to be a rat.

1. Water storage: Show an open container of water, with no cover, on the ground, and show the rat drinking and pissing in the water. Put a cover on the water container and put it on a raised surface off the floor. Also show the 5-gallon with the lid on it. Show the rat trying to get at it, but then giving up and leaving.

2. Cooked Food: Show a plate of food uncovered, on the ground, and the rat eating it. Put the plate of food into a container and cover it, and put it on the table/raised from the ground. Show the rat trying to get at it, but then giving up and leaving.

3. Bin: Show a bin bag with food waste in it on the floor. Show the rat getting in it and eating it. Pick the bag up and put it into the plastic bucket (bin) and put the lid on it. Show the rat trying to get at it, but then giving up and leaving.

4. Dry/uncooked food and rice storage: Show a rice bag open and on the ground, and the rat eating it. Tie the bag, and show the rat eating the side of the bag and getting to the rice. Show an open/uncovered locally used food storage container with various uncooked food stuffs in it (e.g. vegetables, Maggi etc.), on the ground with no cover. Show the rat eating it. Pick up the rice sack and put it into the plastic covered food storage container. Pick up the other food stuffs and put them in the container. Close the lid. Show the rat trying to get at it, but then giving up and leaving.

Ask participants to discuss and explain what they just saw. Ask, are the way we store our food, water, and waste in the house attracting rats?

Shelter: Ask, do we have places in our houses where rats would like to shelter and live/nest in? Explain that possible nesting areas should be cleaned out regularly to prevent nesting.

Skit – Ask the volunteers playing the rat family to come back. Get them to act out having a conversation about how the community used to be a perfect place to live, but now there is nothing available/accessible to eat, no water to get at as they are all covered, and they keep on disturbing where we try to next. Get them to pretend to walk out of the community, saying ‘let’s leave here and find another community where they don’t have a community health club!’

Continue to ask about other prevention methods:

Communal Ask, do we always have enough safe rat proof storage? What about harvest? Discuss the idea of grain storage cribs.

Ask, do we have rat droppings in the home? Are these clean? Explain that rat droppings can contain Lassa and should be cleaned regularly as part of a clean home and cooking area

Ask, whose responsibility is preventing rats entering our community? Is it a problem if some houses are not covering their food, or dumping waste? Explain that rats move from house to house, therefore it is essential that all households and community members take steps to prevent rats in their community.

Ask, how do the rats get in the house? Are there holes and gaps under the door? Explain that the type of rat that transmits Lassa is not a good climber, so blocking low holes and closing gaps under the door etc. can help

Ask a volunteer to be a rat urinating/defecating on the ground, and a baby crawling on the ground, then putting their hand in their mouth. Ask, can there be rat urine/feces on surfaces that we touch? Is it likely to be on the floor where our children crawl? Explain that handwashing is key before cooking, eating, or feeding children

Ask, have any of us ever eaten rats? Our children? Is this risky? Discuss whether the community should allow the eating of rats, or establish bylaws against it?

5. Trapping and Killing Rats

Explain that preventing the rats from entering the village by removing their food and water access, and preventing their shelter is the best. However it is difficult to get all rats away.

Ask, do you know how rats can be trapped and killed? Ask for participants to give various examples, and briefly discuss the positives and negatives of each. Show the flash cards, and demonstrate the snap trap and locally made trap example.

The table below offers some hints for the facilitator, but does not need to all be covered in the discussions.

Example Positives Negatives

Snap rat trap Easy to use, available in local market

Can be dangerous for small children and domestic animals (like cats, chickens...). Requires handling rodent.

Rat glue Easy to use, sometimes available locally

Can be an issue with crawling children/other domestic animals. Requires handling rodent

Rat poison Easy to use, available in local market

Hazardous to children and animals if eaten. Requires handling rodent Not recommended.

Indocin (medicine for humans that kills rats)

Safer than rat poison Requires handling rodent, needs frequent purchase.

Locally made traps Very cheap and locally made, disposable so less rodent handling

Requires regular maintenance and time consuming to make

Cats Less rodent handling, rats fear cats and less likely to enter the houses/area they are in

People eat cats, still some handling if the cat does not fully eat the rodent.

Explain that in some communities, they decided to get cats, and make a bylaw that no one could eat the cats, and the number of rats dropped significantly.

Explain in one community, someone made an income in making local traps for houses and the dump site, and removing them daily.

Ask, once the rats have been trapped, what do we do with them? Are they dangerous? How should they be handled? Where should they be disposed of? Explain that the rats need to be carefully handled, traps

Image Source: Moses/Tulane 2015

Source: Moses/Tulane 2015

cleaned, and safely disposed of by burial in a designated place (not the compost pit, as it may be used for compost later).

Demonstrate taking a rat trap with a (pretend) rat in it, putting a plastic bag over the hand like a glove. Dig a small pit, and put it in, and cover it over. Ask, should I wash my hands now?

Key Messages

Lassa Fever is a very dangerous disease that is often fatal. It is transmitted by the blood, urine and shit of rats

A person showing suspected signs of Lassa should be isolated and call 117

It can be prevented by reducing the attraction of rats to the houses and community. This can be done by proper waste management, food and water storage, and general community hygiene

Keeping communities clean is the responsibility of all the community. One dirty household can bring rats into the village and risk everyone’s lives

Killing rats is also an option, but the rat bodies should be carefully handled and disposed of in a specific place

Actions

Make up a song about Lassa fever and how to keep the village clean and free from rats

Agree on a bylaw against eating rats in the community

Define a place in the community where dead rats should be disposed of

Consider establishing a system of making local traps and removal, maybe paid by the different clubs

Designate specific places for communities to dump food waste, and upgrade them so they are rodent proof

Purchase/adapt food storage and water storage containers that are protected from rats

Discuss the idea of communal food storage and how to keep excess food/grain from harvest protected from rats

Session 22: Onchocerciasis & Schistosomiasis

Session Objectives

To understand the causes, symptoms of and treatment for Onchocerciasis

To identify ways in which Onchocerciasis transmission occurs, and how to prevent it

To understand the causes, symptoms of and treatment for Schistosomiasis

To identify ways in which Schistosomiasis transmission occurs, and how to prevent it

To disseminate information on treating infection

Materials

a few lappas or long-sleeved shirts

Orange/lime/grapefruit

A local walking stick (for blind people)

Flash cards – symptoms of Onchocerciasis, black fly, flash cards illustrating the transmission of schistosomiasis

Session Activities

Explain that this session will cover disease called onchocerciasis (river blindness) and Schistosomiasis (Bilharzia).

Onchocerciasis (River blindness)

Ask, does anybody know someone who has gone blind? Does anybody know someone whose skin has gone white in patches, has gone into nodules or like orange peel? Does anybody know someone who has suffered from elephantiasis – a condition where the groin hangs down and the genitals grow very large?

Explain that these people may have onchocerciasis.

Sources: www.blogs.plos.org; www.opc.asso.fr; www.dermaarin.com; www.emedicine.medscape.com; www.riverblindnessvaccinetova.org

Show the picture of the blackfly – do we have these in our community? Where do they live? Do they bite? When, in the day or night time?

Explain that Onchocerciasis is a sickness that is in the blood, a bit like malaria, that is transmitted by black flies – the flies that live near fast moving water in the river/stream. The sickness can make people go blind if not treated.

Role play

Ask all participants to get up and find a space where they can move.

Get 3 categories of people:

Sources: www.pathologyoutlines.com; www.whi.int

People who are covered on their arms and legs (won’t get bitten)

People who are not well covered on their arms and legs/chest (likely to get bitten)

5 blackflies

Ask 5 volunteers to be the blackfly. Show participants the picture of the blackfly so they know what it is – the little fly that bits near the river.

Ask the people who are the black flies to move around in between all the other participants.

Explain that the flies should only bite the people who are not covered.

Hand some participants a lappa to wrap around their shoulders, or a long sleeved shirt to put on for the people who will be covered up. Explain that you will tell a story and all participants are the actors in the story. This means they must pretend to do what is being described – for example, work in the field, or scratch their bodies.

Story:

Act 1:

Every morning the villagers of X (use a local name indicating ‘by the river’ or something like that) went to their fields to work in the vegetable garden. This garden was near a river and the vegetables looked very healthy. The villagers hoed the ground and pulled out weeds, they planted seeds and picked the crop. (Act like you are doing gardening tasks!) The flies bite the non-covered people.

But some were feeling tired and lay down to have a little rest. (Act tired: lie down to rest)

Meanwhile the blackflies came to bite them (Indicate to the volunteers with pieces of paper that they should move around and tap various participants on their arms and legs. Ask all of the volunteers to tap the people who are lying down, resting or sleeping, and NOT covered).

Stop the play.

Ask, what happens when an infected blackfly bites you?

Explain:

Onchocerciasis is an infection caused by a parasite and spread by the bite of an infected blackfly.

This fly is very tiny and it breeds in fast-running water. It usually bites during the daytime, often when someone falls asleep near the river. When the blackfly bites a person it injects her or him with worms.

Ask the participants who were not bitten, and the flies, to sit down, and the people who were bitten (people who were not covered) to remain standing. Explain that they now have Onchocerciasis, and should act out the symptoms as you read them out.

Act 2:

Continue the story: The bite was not painful, but a few months later many of the people developed lumps under the skin, especially around the hips and chest. These lumps were very itchy (Act like you are very itchy – scratch yourselves). Inside each lump was a pair of worms and these worms produced lots of babies that went on a journey right throughout the people’s bodies.

Stop the play.

Ask, what about those people who wore lappas or long-sleeved shirts – were they also bitten?

And what about the people who were sleeping and many flies bit them?

Answers should indicate the following:

Prevention and spread of onchocerciasis

If you cover up, you are less likely to get bitten.

The more infectious bites a person has the more pairs of worms s/he will have and the more sick s/he may get. Sleeping next to rivers where the blackfly breeds is not a good idea

Act 3:

At first the people were just itchy. Then they began to have pains: in the back, shoulders, hip joints.

(Act having back pain and sore shoulders and hip joints) They could feel that the glands in their groins were enlarged. (Feel the lymph nodes) Then they looked at their skin: when the sun shone on it from the side it looked like orange peel (texture not color). Pass around a grapefruit/lime/orange for people to look at the texture of the peel. (Act inspecting each other’s’ skin.) Some had spots and patches where their skin had turned white. Finally, some complained that their eyes were sore – and they were beginning to go blind. (Act going blind: close your eyes and walk around a bit or prod around with a stick).

Stop the play. Thank participants for acting and ask them to sit down.

ASK: How can you prevent getting infected with onchocerciasis? How can you control the disease?

Explain that the best way is to avoid bites by wearing protective clothing and by not sleeping out of doors during the day – especially near a river.

Treatment of Onchocerciasis

Explain that the government normally provides medicine called Mectizan periodically to people who live in areas at risk. Taking this drug when provided can help to prevent and treat the disease. However the drug is not suitable for pregnant women or children under 5 years.

Suspected cases of the disease should be reported to the health center for treatment, and early treatment can prevent blindness.

Schistosomiasis (Bilharzia)

Symptoms

Ask, has anyone here ever had schistosomiasis or knows somebody who had it? What was it like? Why did you think you had schistosomiasis?

These are some of the responses you should get:

blood in urine – especially in the last drops, blood in the feces

pain in the lower belly and between the legs, especially at the end of urinating

continued tiredness

Explain, Schistosomiasis (or Bilharzia) is a sickness where tiny worms enter your body, a little bit like malaria or onchocerciasis, and infect your blood, especially you’re liver.

Transmission

Ask, how is schistosomiasis transmitted? How do people catch it?

Take some responses, then distribute cards to 8 volunteers. Ask them to look at the pictures on their cards and discuss them for a few minutes with the people sitting next to them.

Ask the 8 participants with cards to come into the circle or to the front one by one, and describe their picture, acting out the contents. They should do this in the order presented above.

Ask the 8 participants to arrange themselves in a line to illustrate the schistosomiasis cycle (the correct order is shown above).

Ask a few volunteers to help act the story. One person is the schistosomiasis parasite, one person the snail, one person an infected person, two people the healthy people (that get infected). Talk through the flash cards in order, as the volunteers act it out. The roles of the volunteers is numbered below.

Schistosomiasis cycle

(1+2) A person who has schistosomiasis has worms (the parasite) in their gut. When they urinate or defecate into or near water the worms (parasite) can get into the water.

(3) The parasite may have gone straight into the water through the urine, or else rainwater may wash the eggs into the stream or water source.

(4) Worms need a certain kind of snail in order to survive. These snails live in rivers and fresh water like swamps. Within 7 days the worms must find a snail that will be their host (the parasite worms will burrow into the snail and live inside it).

(5+6) When people come to the stream to wash themselves or their clothes, or to play in the water or collect water the parasite worms leave the snails.

(7) The parasite worms burrow into the person’s skin.

(8) The worms then travel in the person’s blood vessels to the gut (belly), where they lay eggs.

(1+2) The cycle begins again when an infected person defecates or urinates near a river, putting the parasite eggs into the river.

Prevention of schistosomiasis

Ask, do you think we may have Schistosomiasis in our community? Do people defecate or urinate near streams we bathe in, even upstream?

Ask, how do you think we can prevent Schistosomiasis?

Prompt answers such as:

using latrines rather than open defecating

when in the bush/ at the farm, not defecating or urinating near streams or swamps, and burying the feces after defecating (cat sanitation)

killing the snails

washing at home, using protected clean water, rather than bathing in streams/swamps that may be infected

washing dishes /clothes at home, using protected clean water, rather than being inside the stream

Collecting water from safe sources and not getting in the water to collect it

wearing rubber boots; protecting feet from water

If you bathe in water that may be infected, dry yourself rigorously with cloth/lappa/towel as soon as you get out (but this is not as effective as not getting in the water)

taking medicine to kill the infestation and thus avoid spreading it

Diagnosis and treatment

Ask, how did you find out you had it, and what treatment did you have for it?

Ensure you get the following response:

urine test at health center or hospital, and medication and good nutrition

Explain that only a urine and feces test can show whether there are fluke eggs in the urine; that is why it is important to go to a health center and have a test.

Explain that Schistosomiasis needs to be treated, and medicine can be given at the health center.

Key messages

Onchocerciasis, also called river blindness, is transmitted by black flies that live near the river. They bite in the day time, and can be prevented by covering up skin to avoid bites

Schistosomiasis is caused by people defecating or urinating near water, and then people entering the water. It can be prevented by using toilets, not urinating/defecating near water sources, and avoiding entering potentially infected waters.

Treatment is available for both diseases at the health centers, and people should get tested and treated, to avoid spreading the disease to others in the community

Action

Discuss the signs/symptoms of onchocerciasis with other family members, and examine each other’s skin for lumps that may contain worms and for signs of ‘orange peel’ skin.

Tell family members what you learned today about schistosomiasis and onchocerciasis, and make up a song about its symptoms, transmission and prevention

Make a bylaw against anyone urinating or defecating near water sources, and educate family members (especially children) about the risks of entering potentially contaminated water

Session 23. Ebola

Session Objectives

To understand what Ebola is, and how it is transmitted

To understand how traditional practices of caring for the sick and burials may pose risks, and discuss how these risks can be mitigated

To understand how to prevent Ebola

Materials

A stick or charcoal to draw a line on the ground for the danger discussion

Flash cards

Session Activities

1. Introduction

Ask, have you heard of Ebola? Has it affected this community or surrounding communities? What do you know about it, what happened?

Have a short discussion about people’s understanding of Ebola.

Explain that you want to talk today about Ebola.

Signs & Symptoms of Ebola

Ask, what are the symptoms of Ebola? Ask for a volunteer to act out the symptoms as they are called out. Prompt for answers including the following:

Early symptoms include:

Fever

Severe headache

Muscle pain

Sore throat

More advanced symptoms can include:

Weakness

Rash

Fatigue

Diarrhea

Vomiting

Abdominal (stomach) pain

Unexplained hemorrhage (bleeding or bruising) is experienced in some cases

Ask, how long does it take for people who have been exposed to the disease to develop symptoms? Explain that symptoms may appear anywhere from 2 to 21 days after exposure to Ebola.

Ask, can you survive Ebola? Explain that the fatality rate has reduced considerably, and more and more people are surviving the disease, especially as the government and health facilities are much more prepared and experienced to handle cases. Survival is improved significantly if the disease is identified and treated early, so early identification, reporting and treatment is essential!

Ask, can you recover from Ebola, or do you always have it? Explain that thousands of people in Sierra Leone have survived Ebola. Once they have recovered they no longer have Ebola, and are safe to touch and pose no risk to the community. In fact they are an asset to the community, as they will have developed resistance to Ebola, so can help the community in case of any further outbreak.

2. Transmission of Ebola

Ask, how is Ebola transmitted? Probe for answers including the following:

The first case of an Ebola outbreak can come from bodily fluids from an infected animal coming into contact with a human. Bats, Apes and Monkeys are thought to be potential hosts of Ebola, and eating their meat, and eating food partially eaten by them can be risky.

However after this first case, commonly Ebola cases are from person to person.

To pass from a person to another person, the body fluids (saliva, vomit, breast milk, feces, urine, sweat or blood) of a person showing symptoms/corpse must pass into the body of another person, through blood contact, or via a mucous membrane (e.g. the nose, eyes or mouth) or break in skin (e.g. cut or wound).

Infection can also pass from contaminated sharps such as needles and syringes from an infected person

Infection can also potentially occur from semen from a man that has recently recovered from Ebola

Ask, how can the infection pass from an infected person (or corpse) to a new person? Ask a few volunteers to stand up and do a role play of various transmission ideas.

Prompt to include:

Looking after a sick person and getting their fluids on you

Burying an infected corpse and handling/touching/washing the corpse

Sharing a toilet with an infected person

Shaking hands with/hugging an infected person

3. Danger Discussion

Draw a line on the ground, explaining that one side is dangerous, one side is safe.

Hold up the first flash card. Ask a volunteer to summarize what is on the card (guidance shown below), and then put it above or below the line (e.g. in ‘dangerous’ or ‘not dangerous’). Get participants to discuss briefly if there is disagreement about where it is placed. If there is significant disagreement, put a ‘?’ over the card, and come back to it later. The notes in next to the pictures below are for the facilitator’s guidance, and should not be read out, but can help clarify what the picture is showing (but not whether it is dangerous or not).

Summarize at the end of the process.

Sources of images: Community Led Ebola Action Manual, Social Mobilization Action Consortium (SMAC) 2014.

4. Burial role play and discussion – Traditional burials and possible risks

Ask for volunteers to briefly act out a traditional (non-medical, non-Ebola) burial. The person who has passed is a leader/elder. They are to act out preparing the body, people visiting the corpse, deciding where they would be buried, and the beginning of the ceremony. Stop the role play once the body is placed in the ground (no need to do the whole ceremony – try to keep the role play less than 5 minutes, just showing the key steps). Thank the participants.

Ask, if this person died of Ebola, are any of our customs a bit risky?

Ask, if a pregnant lady dies, is there anything we do that may increase the risk of Ebola?

Ask, where do we normally bury the dead – is it risky in any way?

Ask, if a person passes but it is not known what the cause of death was, what do we do? Is this risky?

5. Ebola Spread Role Play

Ask all participants to stand in a cluster and imagine they are all different family members and neighbors.

Ask one person to pretend to be a sick person with a bad fever (not necessarily Ebola). Other volunteers take different roles – the wife/husband, the children, the parents, neighbors, and pastor/imam. Ask the volunteers to act out what they would do, as you read the text below:

Imagine one member gets sick with a bad fever. Normally, what does the husband/wife do? What do the children do? What does the teacher/pastor/imam do when he sees that this person is not in school/church/mosque and learns that he/she is sick? Who cooks for the sick person? Who takes care of the children?

Let them act out the real interactions between the community/family members.

At the end of the story, ask the volunteers to sit down if they have had ‘contact’ with the sick person. Most of the group will likely be sitting down by the end. Say ‘it is clear this is a real community where everybody helps each other, but now imagine if this person had Ebola, what would have happened to all the people sitting down? Allow people to discuss among themselves. What could have happened? Have they heard of other communities where a large number of members have died?

6. How to prevent Ebola transmission

Ask, how can we prevent Ebola from spreading? Prompt for answers including the following:

Handwashing, and then avoided body contact in the event of an outbreak

Avoid eating bush meat and food partially eaten by animals

Avoiding burials/avoiding handling corpses that may have died of Ebola

Monitoring and surveillance in the community, checking people who seem to have fevers, and early reporting in case of symptoms

Isolation of suspected cases, extreme caution for those providing early care to a suspected infected person

Treat any fluids or surfaces touched by the infected person as highly contagious. Do not share toilets with a quarantined household or suspected person. Disinfect any waste or surfaces using bleach, dispose of items such as bed sheets etc. by burning.

Key Messages

Ebola is real and is highly contagious. Suspected cases should be reported immediately by calling 117 (or other local/district number) or notifying a health care worker. Hiding cases puts the person and community at risk. Contact tracing is important and people should tell the truth about contacts. If the person passes away while waiting for the burial team, wait and do not bury them.

Survival is possible, especially if cases are reported early. Ebola survivors are heroes, and do not pose a risk to the community

Practices of caring for a sick person and preparing/burying the dead can put people at risk of infection, and plans should be developed to reduce this risk if an outbreak were to occur.

Action

Discuss as a community what they may do in the event of a suspected Ebola case or outbreak in the village. Include considerations on:

o Approaches for burials (burial team, protocols for attendance, location of burial site, decisions on alternative ceremony arrangements etc.)

o Reporting deaths or new suspected cases (who would contact 117, roles and responsibilities etc.)

o Home care (e.g. isolation, identification of appropriate care givers etc.)

o Definition of a community surveillance system for screening people entering/exiting the community and check-ups on Ebola contacts

Discuss what was learned with family members

Module 8. Sustaining Total Sanitation & Hygiene Practices

Session 24: Using & Maintaining the Toilet

Session Objectives

Understanding the importance of keeping the toilet clean and hygienic

Understanding the need to allow all users to be able to use the toilet, and the importance of teaching them how to use it properly

To identify and discuss together cultural issues relating to toilet use, to ensure consistent use of the toilet

To identify ways to ensure that people continue to use toilets and never return to open defecation

Materials

Bucket with water to fill the tippy tap

A tippy tap

Examples of anal cleansing items (local wiping materials)

Plastic kettle

Palm oil

Child’s potty (plastic stool) / item used for cleaning child’s potty

Raffia brush

Scrubbing brush (one to scrub the latrine slab surface)

A small container with ash in it and scoop (use materials in the community)

Tippy tap, soap/ash

A bucket of water

Flash Cards showing the intestinal worms entering feet, and planting tree in old pit)

Session Activities

1. Introduction

Say, so now we all/many of us have toilets. Do you think a badly maintained toilet can be a source of disease? How? Discuss.

Role play a person to demonstrate using a badly maintained toilet carelessly, and ask for a volunteer to pretend to be a fly. Use ash/palm oil to simulate it. Include:

A person missing the squat hole, and not cleaning it after (spread ash around the slab)

Not replacing the cover

Going to the tippy tap, but there is no water in it/no soap, and wiping hands and returning to shake hands after the toilet

Ask, if the toilet becomes dirty and unpleasant, is it likely that people would prefer to use the bush? Discuss experiences of previous toilet use with the CLTS toilets, and why they returned to the bush. Allow participants to explain why they returned to the bush, what they did not like about the previous toilets, how they could avoid this in future.

Ask, is having toilets the final step, or is this the beginning? Do we want to return to open defecation in future?

Ask, how do we ensure we do not go back to open defecation after a few years? Discuss.

2. Cultural Issues/Beliefs in Toilet Use

Ask, are there any cultural or social issues in using toilets – e.g. not using the toilet after your mother in law etc. Discuss briefly.

3. Teaching Children to Use the Toilets

Role play - Ask a volunteer to pretend to be a mother telling the child to defecate in the toilet, and a volunteer to be a child, who is scared of the toilet, and does not know how to use it, and makes it dirty by missing the hole, not cleaning themselves properly, not washing hands after use..

Ask, once you have made a nice toilet, will you allow your children to use it, even if they make it dirty? If not, where will they go?

Explain that using a toilet is a behavior that needs to be learned, and patience and teaching is needed. Ask, whose responsibility is it to teach the children how to use it properly?

Ask, what are the key things that you would need to teach a person who is new to using a toilet?

Ask the volunteer to act being a mother teaching/encouraging their child how to use the toilet. Prompt for answers/actions such as:

Where to stand, how to aim into the hole

To put wiping materials in the toilet after use, and not re-use

Or to use enough water to clean themselves/cleaning themselves properly

To clear up any mess after use, disposing it into the toilet hole

To replace the cover after use, using their feet rather than hands

To wash their hands after use, with soap

4. Odor and Fly Control – ash and cover

Ask, how can we stop getting the toilet getting smelly and breeding flies in it?

Ask, do flies breed in the toilets? Explain that up to 10,000 flies can breed in 1kg of fresh kaka.

Explain that by putting a little ash in the pit after defecating, it can dry the kaka, and cover it slightly, and flies are less likely to land on it, and it absorbs some of the moisture to keep odors down.

Ask, how can we make ash available in the toilets? Show the small container with scoop, and ask a volunteer to demonstrate removing the cover, defecating in the hole, putting a scoop of ash inside, and then covering it again.

Ask, if the cover does not fit well, or is not placed correctly, is it a problem?

5. Wearing Slippers in the Toilet

Ask, should we go into the toilets with bare feet? Why not? Remind the participants (from the intestinal worms session) that parasite worm eggs can live in the surface of the toilet, especially if it is made from earth. Therefore all users (including their children) should always use slippers when visiting the toilet.

6. Maintaining the Tippy Tap and Maintaining the Toilet Hygiene

Ask, if the tippy tap is empty, is it effective? If it has no soap or ash, is it effective? If the ash container is empty, is it useful?

Ask, how can the latrine be kept clean and tidy, and items kept refilled? Whose responsibility is it? Discuss.

Ask, what should we use to clean the toilet slab? Explain that ash and water can be effective at cleaning. Ask, should the same brush/cloth to clean the toilet be used for other purposes (e.g. kitchen cleaning etc.)?

Ask, what should we have inside and outside our toilets to ensure they are clean and hygienic? Prompt for answers to include:

Anal cleansing material/kettle

Cover

Ash container and scoop

Brush

Tippy tap outside with water and soap

7. Repairing the Toilet and Continuous Upgrading

Ask, can we upgrade our toilets through time, or do we need to construct it perfectly at the beginning? What items could be improved through time? Answers could include upgrading the walls, concreting the slab, getting a zinc roof etc.

Ask, when some of us used toilets before (e.g. CLTS toilets), what led us to returning to open defecation? What problems did the toilet develop?

Ask, do we need to maintain the toilet building once constructed?

8. Monitoring the Hygiene of the Toilets

Ask, is it a problem for me if my neighbor’s toilet is dirty? Why?

Ask, should we as a community/club have a system to monitor the toilets in the community, to ensure they are all kept in a hygienic way? Who should do this? How should issues be addressed?

9. What to do when the Pit is Full

Source: www.wawash.fiu.edu

Ask, what can be done when the pit is getting full? Should we use it until it is nearly at the surface?

Explain that once the pit contents are within 50cm of the slab, to dig a new pit. The same slab could be used on the new pit (e.g. if it is a casted concrete slab).

Ask, what should be done with the old pit?

Explain that it should be well covered with soil, and you can plant a fruit tree in it – it will grow very big!

Key Messages

Even if all households have and use toilets, if they are kept unclean, it can be health risk for the whole community

Toilets can be kept clean by regular cleaning, adding ash to the pit, replacing the cover after use

An empty tippy tap is a useless tippy tap

Children and new users should be taught how to use the toilet properly, and not prevented from using it

A toilet that is badly maintained will be unpleasant for the user, and may make them prefer to return to the bush

All households having toilets is a massive achievement, but it is only the beginning, the important point now is to ensure they are kept clean, and repaired/replaced rather than returning to the bush

Actions

Make up a song about keeping the toilet clean and tidy and refilling the tippy tap

If needed, teach your children how to properly use the toilet and clean themselves

Agree in the household if appropriate how/who would keep the toilet clean, and fill up the ash container/tippy tap

Place a broom and ash container/scoop in the toilet

Image adapted from source: wikiwater.fr

Session 25: Revision / Quiz

Session Objectives

To revise key messages of the first phase of the course

To monitor participant’s understanding and knowledge

To build and improve memory

Materials

List of questions

Flash cards from all the sessions

The manuals for all sessions 1-24.

Session Activities

1. Introduction

Explain that this is the last session for phase 1, which has covered hygiene, sanitation, basic health topics and key preventable diseases. This is now an opportunity to recap on the key messages from the sessions.

2. Quiz

Ask all participants to stand up. Explain that you will ask a range of questions: the first person to put their hand up and answer the question right must sit down. After that, another range of questions will come when everyone has to stand up. The game finishes when everyone is standing up again.

Ask the questions in the table below, and add questions wherever you feel appropriate.

Question Guidance/ Correct Answer

How should we give feedback about their personal hygiene issues?

With respect, politeness and tact

Hold up body map – ask to identify lungs, stomach, intestines

Hold up body map – ask (1) where worms live (2) where diarrhea affects (3) where pneumonia affects

(1) intestine (2) intestine (3) lower lungs

Identify 5 ways to prevent diarrhea Handwashing, toilet use (with cover), cover food from flies, drinking clean water, good food hygiene...

Why should you wear slippers in the bush/toilet in terms of disease prevention?

Intestinal worms can live in soil where people defecate, and can burrow into your foot and infect you

When are the key times to wash your hands to prevent diseases

After the toilet, after cleaning a child/babies kaka, before cooking, before eating

Why is water not enough to wash hands? Soap or ash are needed for effective dirt removal

Where should dirty water from washing a baby’s nappies, or child’s kaka be disposed of?

In the toilet

Who should you go to/where if your child is very sick with pneumonia/diarrhea/malaria

The CHW and/or the health facility

Why is it important to go to the CHW/health center as quickly as possible rather than delaying

Early treatment improves the child’s chance of survival

What can you use to brush your teeth? Local chew sticks, tooth brushes, tooth paste/salt/ash

How can you prevent scabies and ringworm? Regular body washing with soap, regular washing of bedsheets/clothes with soap, and hanging in the sun off the ground

List 3 things to avoid to keep your body and immune system healthy

Drinking or smoking heavily, a bad diet, not enough sleep/rest, poor hygiene and sanitation practices

How can you contaminate water stored in the home, and how can this be avoided?

Dipping a dirty cup/hand in to scoop the water, leaving it on the ground and uncovered.

Prevent by raising and covering the container, and using a Bailer. Alternatively using a 5-gallon jerry can with lid

How can we protect our water source from being contaminated?

Wash hands before collection, use a well lid, drainage of waste water, sealing cracks in headwall/lid, using a dedicated bucket and rope suspended off the floor, use toilets, locate toilets 30m away from water sources

If water we drink has kaka in it, can we always see it?

No, water can appear clean but can be unsafe to drink

What can we do if we collect water from unprotected sources like open wells and streams, to make it safer to drink?

Boil it.

If it is muddy, first strain through a cloth/leave to settle, then boil it.

If all households aside from one in the community uses a toilet, is it a problem? Why?

Yes. Any open defecation in the community, even from one person, can contaminate the food and water we drink and make us sick.

Where should we dispose of our household wastewater e.g. (from cooking and bathing children)

In a soak away pit (small pit filled with small stones to promote soaking into the ground rather than pooling on the surface

What are the 3 essential features of a toilet to ensure it prevents disease?

A stable slab, a cover over the squat hole, a tippy tap

How can we control flies and odor in our pit toilets?

Cover the squat hole. Pour a small scoop of ash into the pit after each defecation.

What do we do when the toilet is nearly full? Dig a new pit, re-use the slab (if possible). Cover the old pit fully with soil and plant a fruit tree.

What is the important features of a child’s stool (potty)?

A cover, easy to clean

What key items should a child be taught about using a toilet?

How to get the urine/feces in the hole, to clean up any mess and put into the toilet, to replace the cover, to clean themselves properly, to wash their hands after defecating

What can you do if you need to defecate whilst on patrol/at the farm if there is no toilet?

Cat sanitation (did a small pit and bury the kaka)

How should we store household (e.g. food) waste and why?

Store in a covered, insect/rodent proof container before taking to the dump site. To prevent rodents/mosquitoes/flies etc.

What are the key features of a community compost pit?

Steep sides to prevent Lassa rats climbing in/out, a fence for animals and child safety, located not too close to houses

If you want to eat yesterday’s rice and plassas, what should you do first? Why?

Heat it thoroughly so it is very hot/boiling before eating it, to kill the germs, especially on meat/fish

Is it safe to use the same knife/surface to cut raw meat/fish and then cut fruit to eat? Why?

Raw meat and fish contain harmful bacteria. Surfaces and knives and hands that touched raw meat/fish should be washed before using them for other purposes.

What should you do before eating fruit that you cannot peel? Why?

Wash it with clean water, to prevent disease

Name 4 key symptoms of diarrhea dehydration in babies

Sunken eyes, wrinkled skin (that is slow to release after a pinch), sunken fontanelle, no tears when crying, no urine

What should you do if your child has diarrhea? If a breastfeeding baby, give more breast milk. If older than 6 months, give ORS/sugar salt solution, or other products (‘jelly water’, coke/Fanta)

Take them to the CHW/health center

How can you prepare local ORS? (the sugar salt solution)?

1 cup of clean water, 3 teaspoons of sugar, salt on the end of one teaspoon. It should taste like tears.

What are common symptoms of intestinal worms

Itchy anus, swollen belly, cough, belly ache, nausea, ‘ground itch’

What should you do if you think your child has worms?

Take them to the CHW/health center for treatment

Name 4 ways to prevent Malaria Use a bed net, cover up in the evening before bed, mosquito screen on windows, burn mosquito repellent, drain surface water pooled in the community, use soak ways, clear garbage in the community

Which members of a family should have priority for the bed nets if there are not enough for everyone?

Pregnant/lactating women, children under 5 years

What should you do if your child has acute diarrhea, malaria, worms, pneumonia

Report to the CHW/health center for treatment

What should you do when you sneeze? Sneeze into your elbow

What are the key symptoms of pneumonia in young children?

Fast and shallow breathing, lower chest breathing

Should children live in smoky environments? Why?

No. It will damage their lungs and make them at risk from respiratory infections such as pneumonia

How is Onchocerciasis (river blindness) spread, and where do you normally get it?

From black flies biting you. They live near fast flowing sections of rivers/streams.

How can you prevent Onchocerciasis (river blindness)?

Cover up when near the river and avoid sleeping by the river

What are the signs and symptoms of Onchocerciasis (river blindness)?

Blindness, eye pain, itchy rash/nodules, white patches on skin, skin with the texture of orange peel, elaphantitis, aching joints and back/shoulders

How is Schistosomiasis (bilharzia) spread? Through an infected person urinating/defecating into/near water, the parasite getting into snails, a person getting into the water and the parasite entering their body.

What are the signs and symptoms of Schistosomiasis (Bilharzia)?

Blood in urine/feces, persistent tiredness, pain in the lower belly.

How can you prevent Schistosomiasis (bilharzia)?

Avoid entering potentially contaminated water, use clean water to wash/launder, dry off vigorously if you have entered the water, use toilets and avoid urinating/defecating near streams or other water sources

What are the signs and symptoms of Ebola? Fever, headache, sore throat, rash, vomiting, diarrhea, sometimes bleeding/hemorrhaging.

What do you do if you think someone has Ebola? Isolate the person and dial 117/local emergency number immediately.

How is Lassa Fever transmitted? Through the blood, urine, feces and saliva of a certain type of rats, infecting someone.

It can also be passed from infected person to new person, but most commonly it is from rats.

Name 5 ways to prevent Lassa Fever Stored domestic water, stored domestic food/rice, covered domestic waste, a well-built community dump site, disturbing possible shelter sites in the

home through regular cleaning, use of soak ways, trapping and killing rodents

Are trapped/dead rats safe to handle? How should they be handled?

No, they may have Lassa. They should be handled with care, using plastic bags as gloves, and buried in a specific place. Hands should be washed after this.