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This article consists of a review article reporting the results of previous evaluations of the control of water, sanitation, and hygiene (WASH) related disease through the Community Hygiene Club (CHC) intervention from 2010 to 2020. CHC constitutes the main intervention for the control of WASH-related disease in Rwanda and is implemented countrywide. The study objective was to evaluate if the CHC intervention significantly reduced the prevalence of WASH-related disease after 10 years of its implementation in Rwanda. The study utilized online existing policy documents, research reports, and experiences on the CHC intervention in Rwanda published between 2010 and 2020. We selected and reviewed 12 published documents, and the evaluation followed the steps proposed by ACHI (2020) Health Impact Assessment (HIA) and related frameworks of effective implementation of community health interventions. The primary outcome measure used was the reduction of WASH-related disease while the secondary outcome measure used was the increase of household WASH practices at less than a 5% level of statistical significance. We also described the structure and the implementation process of the CHC intervention. From the case studies where frameworks of effective implementation of community health interventions were applied, the study results showed the intervention significantly (a) increased households’ WASH practices and (b) reduced WASH-related disease. Due to limited publications in the research area and the lack of association of the WASH-related diseases and practices to the CHC intervention’s evaluation for most of published research reports, we recommend additional field data for an extended conclusion and its generalization in Rwanda. The study highlights the need to use appropriate frameworks in the evaluation of community health interventions to (a) attribute the outcome to the intervention and (b) easily identify the shortcomings in case of failure to get expected outcomes.

Water sanitation and hygiene-related disease and malnutrition are a high priority in developing countries, including Rwanda. Interventions that can trigger and sustain household-level behavioral change and practice are needed. A case-control study was conducted to assess the potential of the Community Health Club (CHC) intervention, which consisted of village-based health education on water sanitation, hygiene, nutrition, and monitoring of households’ practices to reduce water sanitation and hygiene-related disease and malnutrition. The study targeted one village which had been exposed to the CHC. As a control, one village was picked from among villages that had not been exposed to CHC intervention. The two villages were in the catchment area of the Nyabitimbo Health Center and shared the same water sources for domestic use in the Rusizi district in Rwanda. The study examined the prevalence of intestinal worms, diarrhea, and malnutrition among children under 5 years old as recorded in the registries of Nyabitimbo Health Center for the period of the study, 2013–2015. The study results revealed that the CHC intervention was associated with a reduction of intestinal worms, diarrhea, and malnutrition, but the results were only statistically significant for intestinal worms and malnutrition. The present study, being exploratory, can serve for planning and practice purposes at the specific study area.

Effective implementation of health interventions is critical for maximum adoption and optimal health outcomes. This qualitative study assessed the differences in Community Health Club (CHC) implementation in villages using qualitative research methods. Villages in Rusizi district in Rwanda were purposively selected with high, medium, and low adoption rates. The results revealed that the traits and skills of intervention facilitators (providers or implementers) at the village level, the involvement of the head of the village in the CHC intervention activities, and the support supervision by the Community Environmental Health Officer from the health center may have contributed to high rates of adoption of the intervention. Poor community organization, mistrust, lack of equal consideration among intervention beneficiaries, and lack of skills and capacity for intervention facilitators may have contributed to the low rates of intervention adoption. The results of this study suggest the need for capacity building of implementers, local leaders, and supervisors for improved (1) skills to adapt to local contexts and maximize the intervention adoption, (2) involvement and participation of local leadership, and (3) support supervision, guidance, and close monitoring, respectively. for effective implementation and maximum adoption of CHC intervention.

Background A cluster-Randomised Controlled Trial evaluation of the impact of the Community Health Clubs (CHCs) in the Community Based Environmental Health Promotion Programme in Rwanda in 2015 appeared to find little uptake of 7 hygiene indicators 1 year after the end of the intervention, and low impact on prevention of diarrhoea and stunting. Methods Monitoring data was revisited through detailed community records with all the expected inputs, outputs and external determinants analysed for fidelity to the research protocol. Five household inventory observations were taken over a 40-month period including 2 years after the end of the cRCT in a random selection of the 50 intervention CHCs and data compared to that of the trial. Focus Group Discussion with all Environmental Health Officers of the Ministry of Health provided context to understand the long-term community dynamics of hygiene behaviour change. Results It was found that the intervention had been jeopardised by external determinants with only 54% fidelity to protocol. By the end of the designated intervention period in June 2014, the treatment had reached only 58% of households with 41% average attendance at training sessions by the 4056 registered members and 51% mean completion rate of 20+ sessions. Therefore only 10% of 50 CHCs provided the full so-called ‘Classic’ training as per-protocol. However, sustainability of the CHCs was high, with all 50 being active 2 years after the end of the cRCT and over 80% uptake of recommended practices of the same 7 key indicators as the trial was achieved by 2017. Conclusions The cRCT conclusion that the case study of Rusizi District does not encourage the use of the CHC model for scaling up, raises concerns over the possible misrepresentation of the potential of the holistic CHC model to achieve health impact in a more realistic time frame. It also questions the appropriateness of apparently rigorous quantitative research, such as the cluster-Randomised Controlled Trial as conducted in Rusizi District, to adequately assess community dynamics in complex interventions.

Additional file 1. Househole Inventory Monitoring Tool.

Two similar Community Health Club (CHC) interventions to achieve hygiene behaviour change and improved family health in Africa took place—one in Zimbabwe implemented by an NGO and the other in Rwanda as part of a Randomized Control Trial. Both interventions achieved high levels of community response, although the Zimbabwe project was more cost-effective, achieving blanket coverage of all households in the area with over 90% compliance in 12 recommended practices at a cost of US$4.5 per beneficiary in 8 months. In Rwanda, the spread of the intervention reached only 58% of the households in the first year costing US$13.13 per beneficiary. By the end of three years, the spread had increased to 80% with over 80% of the 4056CHC Members adopting 10 new practices without any extra cost to the project. Although the Zimbabwe program showed better Value for Money, being more efficient, long term sustainability to prevent slippage of hygiene behaviour change depends on a strong monitoring system. Scaling up hygiene behaviour change is best achieved systematically by building the capacity of the Environmental Health Department to take responsibility for the supervision of CHCs in every village. Investing in an integrated national program, which can enable Government to coordinate NGO efforts, is a more cost-effective use of scarce resources in the long term.