Increasing Hand Washing in Kamuganguzi

MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY
FACULTY OF MEDICINE
DEPARTMENT OF COMMUNITY HEALTH
KAMUGANGUZI HEALTH CENTRE III
PROJECT
INCREASING HAND WASHING FACILITY COVERAGE IN KAMUGANGUZI VILLAGE AS A

PREVENTIVE MEASURE AGAINST DIARRHEA
JUNE-JULY 2019
LEADERSHIP AND COMMUNITY PLACEMENT REPORT TO THE DEPARTMENT OF COMMUNITY
HEALTH, MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY, IN PARTIAL FULFILLMENT OF THE
REQUIREMENT FOR THE AWARD OF BACHELORS DEGREE OF PHARMACY, MEDICAL LABORATORY,
PHARMACEUTICAL SCIENCES, PHYSIOTHERAPY, MEDICINE AND SURGERY, AND NURSING.
GROUP MEMBERS
BWEYAGERA JAMES 2015/MBR/025

TWONGYEIRWE DOREEN KAGINA 2017/BNC/022/PS
GOBERA BOAZ 2017/PHA/020/PS
MUHUMUZA APOLLO 2018/MLC/023/PS
ANTHONY ABAHO 2016/BSP/010/PS
ATUKUNDA PROSPER 2018/MMLC/012/PS
AGABA AMON 2018/PHS/080/PS
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Kamuganguzi Health Centre III –June-July 2019
DECLARATION
We declare that the work presented in this report is our own to the best of our knowledge and it has never been
submitted to any university or institution of learning for any academic purpose.
Signature: …………………………………….. Date: ……………………………………
MUST SUPERVISOR (Ms. Owokuhaisa Judith)
DEDICATION
We dedicate this report to Kamuganguzi H/C III, Village Heath team of Kamuganguzi village (Ms. Kenema Grace,
Ms. Tumusiime Anna and Ms. Busingye Nowelina), The Chairman LC1 of kamuganguzi village - Mr. Bicungura
John, and the entire Kamuganguzi community who have been exceedingly cooperative and supportive towards
the success of our project.
ACKNOWLEDGEMENT
We acknowledge Mbarara University Of Science and Technology, and its department of community health in particular, for the
academic support, through first conducting a training, and financial support given to us during the community placement
program.
We also acknowledge the in-charge of Kamuganguzi Health Centre III (Ms. Twesigomwe Janet), and her staff including the
VHTs who, through their teamwork, have enabled our project be a success.
With great pleasure, we also thank the entire kamuganguzi community for their cooperation and willingness to learn which has
not only improved its health but also enabled our project to be a success.
Special appreciation goes to our MUST Supervisor (Ms. Owokuhaisa Judith) for the technical guidance rendered to the team
and Mr. Ntaro Moses for the good coordination which ultimately led to effective implementation of our project in kamuganguzi
village-kacerere ward.
Finally, we acknowledge the team members, that is, Abaho Anthony; BSP student, Agaba Amon; PHS student, Gobera Boaz;
B.Pharm student, Bweyagera James; MBChB student, Atukunda Prosper; ,MMLC student, Twongyeirwe Doreen; Nursing
student, and Muhumuza Apollo; MLS student, for the team work portrayed during the community placement program.
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ABBREVIATIONS
MUST Mbarara University Of Science And Technology
HC Health Centre
VHT Village Health Team
LC Local council
AIDs Acquired Immunodeficiency Syndrome
LCP Leadership community placement
MCH Maternal and Child Health
GISO Gomborora Internal Security Officer
DHO District Health Officer
CAO Chief Administrative Officer
MOH Ministry Of Health
HIV Human Immunodeficiency Virus
OPD Out Patient Department
IPD In Patient Department
ANC Antenatal Care
ART Anti-Retroviral Therapy
RTI Respiratory Tract Infection
FP Family Planning
UTI Urinary Tract Infection
B Pharm Bachelor Of Pharmacy
MBChB Bachelor Of Medicine And Surgery
MLC Bachelor Of Medical Laboratory Science, Completion program
MLS Bachelor Of Medical Laboratory Science
PHS Bachelor Of Pharmaceutical Sciences
MMLC Bachelor Of Medical Laboratory Science, Completion program Mulago Campus
BNC Bachelor Of Nursing Science, Completion program
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Table of Contents
ABSTRACT ........................................................................................................................................................... 6
INTRODUCTION .................................................................................................................................................. 7
BACKGROUND ................................................................................................................................................... 8
Description of placement ............................................................................................................................. 8
Purpose of placement ................................................................................................................................... 9
Placement site ................................................................................................................................................. 9
Output of placement .................................................................................................................................... 10
PROBLEM ANALYSIS/CHALLENGE IDENTIFICATION........................................................................... 10
Environment scanning/community diagnosis...................................................................................... 10
Transect walk ......................................................................................................................................... 10
Review and analysis of health records at Kamuganguzi HC III .................................................. 12
Patient clerking at the health facility ................................................................................................ 14
Key informants ...................................................................................................................................... 15
Focus group discussions ...................................................................................................................... 15
Home visits ............................................................................................................................................. 16
Community dialogue meeting. ........................................................................................................... 16
Challenge prioritization .............................................................................................................................. 17
Root cause analysis – the fish bone and 5 whys technique............................................................. 18
The fish bone technique ............................................................................................................................. 18
The five whys technique ............................................................................................................................ 19
Stakeholder analysis- interests and concerns ..................................................................................... 19
Prioritizing Actions ...................................................................................................................................... 20
Priority matrix ........................................................................................................................................... 20
THE CHALLENGE MODEL ............................................................................................................................. 22
ACTION PLAN ................................................................................................................................................... 23
Description of the interventions (priority actions) to deal with the challenge by stake holder. ...... 23
Procedure of making a tippy tap. ............................................................................................................ 23
Table Showing Action Plan .......................................................................................................................... 24
Comments on how implementation of the plan went by the team......................................................... 26
EVALUATION ..................................................................................................................................................... 26
LIMITATIONS ..................................................................................................................................................... 27
COMMENTS ON THE PLACEMENT BY TEAM MEMBERS ..................................................................... 27
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CONCLUSION .................................................................................................................................................... 28
RECOMMENDATIONS ..................................................................................................................................... 28
APPENDIX .......................................................................................................................................................... 29
Check list ......................................................................................................................................................... 29

Questionnaire ................................................................................................................................................. 30
Pictorial ........................................................................................................................................................... 31
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ABSTRACT
Introduction:
The Leadership and Community Placement (LCP) program, which is aimed at instilling leadership
knowledge and skills in students for confronting the health challenges of the 21st century, is done
annually in Mbarara University of Science And Technology (MUST). It was preceded with a one-week
training at the University, where we (team members) were equipped with the knowledge and skills, by
using group discussions and assignments, role-plays, case studies and to a lesser extent lectures, that
enabled us to conduct our activities effectively while in the community - Kamuganguzi village in kabale
district.
Challenge identification:
The community [Kamuganguzi village] was scanned by use of methods like transect walk [which mainly
involved observation], the review of health facility records, home visits, interview of key informants,
patient clerking and community meetings, various health challenges were identified in the community.
Using the challenge prioritization matrix, “Very few hand washing facilities” was our priority challenge.
Mission:
“To improve the health of the community by increasing hand washing facilities as a preventive measure
against diarrheal diseases.”
Vision:
“A healthy Kamuganguzi community free from diarrheal diseases”
Challenge:
“How will we increase the handwashing facilities from 3% to 40% in Kamuganguzi village despite the
low knowledge and skills of the community on how to make hand-washing facilities?”
Current situation:
“Of the 70 households sampled in Kamuganguzi village, only 2 [3%] have hand washing facilities”.
Implementation:
In order to increase handwashing facilities, four major priority actions were performed, for-instance,
Sensitization of the community about the relevance of hand washing, Demonstration to Village Health
Team [VHT] on making hand-washing facilities, Demonstrations for hand-washing facilities in the
community, and Constructing hand-washing facilities in sampled homesteads. In addition, the
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construction of new latrines, latrine covers, and shutters was encouraged to improve sanitation. A health
talk at Kamuganguzi Janan Luwum memorial secondary school was also done where students were
sensitized about good hygiene (fingernail trimming, bathing often, washing and ironing cloths, brushing
teeth after every meal), good sanitation (cleaning the compound, washing hands after visiting the
latrines/toilets and before eating), Urinary Tract Infections [UTIs], Human Immunodeficiency Virus [
HIV], safe male circumcision.
Evaluation:
Evaluation was based on the number of households with a hand-washing facility (tippy tap) at the latrine
and then the percentage of households with a hand-washing facility (tippy tap) at the latrine. After the
intervention, 33 [47%] of the 70 sampled homesteads had a hand-washing facility near the latrine. We
also urged the community to construct more latrines, latrine covers, and latrine shutters in order to
maintain good sanitation. The measurable result of 40% of homesteads with handwashing
facilities was attained. Fortunately, the measurable result was exceeded and by 14th July, 2019
47% of homesteads had a standard hand-washing facility at the latrine.
INTRODUCTION
Sanitation refers to the provision of facilities and services for the safe disposal of human urine and
feces. Sanitation also refers to the maintenance of hygienic conditions, through services such as
garbage collection and wastewater disposal. Universal access to sanitation is a fundamental need and
human right. Its main objective is to promote and protect human health by providing a clean environment
and breaking the cycle of diseases.
Inadequate sanitation is a major cause of disease worldwide and is linked to transmission of diseases
such as cholera, diarrhea, dysentery, hepatitis A, typhoid and polio. Therefore, improving sanitation is
known to have a significant beneficial impact on health both in households and across communities.
The habit of hand-washing has a great impact towards disease prevention since most of communicable
diseases are transferred by touch and on addition, washing hands with soap and water greatly
decreases diarrheal-associated deaths. Therefore, to have a greater impact in the community on
sanitation, hand and water hygiene, we created public awareness about the relationship between poor
hand and water hygiene and diseases.
Hygiene is a set of practices performed to preserve health. Hygiene refers to conditions and practices
that help to maintain health and prevent spread of diseases. Hygiene includes personal habit choices
such as how frequently to bathe, wash hands, trim fingernails and change clothing. It also includes
attention to keeping surfaces in the home and workplace, bathroom, pit latrine or toilet clean and
pathogen free.
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Hand hygiene entails keeping the hands clean, free of soil and microorganisms. This is achieved
through washing the hands every after visiting a latrine, every after contact with dirty surfaces, whenever
the hands are soiled and after interface with microbe-rich materials, and most importantly before eating
food. Water and soap are used in the process of hand washing though other anti-microbial liquids can
be used like alcohol. Hand washing is simple, cheap, affordable and of benefit to both the individual
practicing it and the community in relation to prevention of spread of most infectious diseases. It involves
five simple steps that is to say; wet, lather, scrub, rinse and dry the hands. These steps can be
undertaken to reduce and prevent the spread of diarrhea.
Hand washing with soap and clean water is the easiest, effective and affordable way to prevent diseases
and save lives. Despite its effectiveness, people rarely use water and soap after visiting a latrine/toilet
because they lack hand-washing facilities at the latrine/toilet. There is need for proper sanitation
practices like hand washing. Therefore, with the introduction of tippy taps which in conjunction with the
pit-latrine covers and shutters, sanitation is improved and a reduction of diarrheal cases is anticipated.
BACKGROUND
Description of placement
Leadership and Community Placement (LCP) course emphasizes a multidisciplinary approach to understanding
and addressing of healthcare challenges in community settings practically. The course is always done annually
and is geared towards instilling leadership knowledge and skills essential for confronting the health challenges of
the 21st century.
A community placement is preceded by classroom-based sessions (which ran for one week in 2019) that employ
interactive student-based learning methodologies, using group discussions and assignments, role-plays, case
studies and to a lesser extent lectures.
Later, the community-based activities phase starts (which ran for four weeks in 2019) where students are placed
within different host communities, especially the needy hard to reach areas. They also reside at and participate in
the host health facilities. Students rotate and participate in health facility based activities during the mornings and
participate in understanding and addressing prevailing and emerging health problems within the communities
during the afternoons where applicable, guided by the course guidelines. The students are required to at least
learn and understand the constraints and opportunities that retard or promote good health in the community. They
appreciate that communities have the potential to identify and provide solutions to many health problems. Their
work involves, but not limited to the following broad areas: environmental sanitation, disease control, obstetric and
surgical care, use and misuse of common drugs, health education, nutrition, communicable diseases, and child
health. Together with host communities, students identify and prioritize community health and health care issues.
They carry out community meetings/seminars and home visits during and facilitate discussions on preventive
aspects of health care. An added incentive is practicing within a rural health facility setting in order to understand
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constraints of rural health and healthcare. During this community –based activities phase, teams share with each
other and with the host health-facility personnel, what they learn throughout the process of implementing their
leadership project. The course is assessed by MUST Faculty supervisors, in conjunction with Site Supervisors,
who play the role of coaches/tutors to the teams and are expected to meet regularly with students, to review the
LCP course content and to support progress. The MUST lecturer is expected to constantly follow up the
performance of individuals and groups through writing a performance report at every visit. On finalizing the
community based activities, students are expected to present a report, assessed by the Faculty that attracts marks
that will feature prominently on the academic transcript. The coaches support student teams to prepare the final-
results presentation.
Purpose of placement
The LCP Course is intended;
1. To introduce students to leadership and management in health and the tools required to identify the main
health challenges within their area of influence.
2. To introduce students to the tools required to focus on priority areas for intervention.
3. To introduce the tools, skills and techniques required to create solid, logical and coherent action plans
that guide students towards achieving measurable results.
4. To introduce the tools and techniques for aligning and mobilizing populations to address health care
challenges.
5. To introduce the tools, technique and strategies for inspiring, and inspired, leadership, to address existing
and future health care challenges.
6. To train students in communities and rural health units under conditions similar to those in which they will
eventually work as qualified doctors.
7. To enable students and community members to interact and learn from each other in order to appreciate
each other in order to appreciate each other’s role in health care and delivery.
Placement site
Kamuganguzi Health Centre III is located on the Kabale-Katuna highway, about 18 km from Kabale town and 2.5
km to Katuna border. It is one of the health centre IIIs in Ndorwa west health sub-district. The health facility serves
five wards-that is, kiniogo ward, kacerere ward, kyonyo ward, Mukarangye ward, and Nyinamuronzi ward; other
parishes from kamuganguzi sub county which include, mayengo parish, buranga parish, Kisaasa parish, kyasaano
parish, Kasheregyenyi parish, Kicumbi parish and Katenga parish; and other communities from Rwanda,
especially when the border is open. Kamuganguzi Health Centre III is owned by the Government of Uganda under
Ministry of Health and has a staff of 19 members. The health centre serves a target population of about 14,406
[as told by the Health facility in-charge]; with an operating Out Patient Department [OPD], maternity ward,
laboratory and Human Immunodeficiency Virus [HIV] clinic. The people who live in Kamuganguzi are mainly
Bakiga and Banyarwanda. The major language spoken by locals is Rukiga but some people speak Runyarwanda.
The main economic activities in Kamuganguzi Sub County are animal rearing, stone quarrying, and crop growing.
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Main crops grown include Irish potatoes, Sweet potatoes, Bananas, and maize. Livestock reared include cattle,
pigs, goats, and poultry.
The weather in this region is mainly cold with occasional rain showers and sunny days. The terrain is hilly with
valleys and rivers. Springs are the main source of eater.
Output of placement
At the end of the LCP, we gained the essential skills and tools required for playing a leadership role in our work
environment. In addition to the grounding in primary health care, community diagnosis, health systems, and family
medicine, we were introduced to leadership and management. A cross cutting expected course output will be
‘health managers who lead’ for effective implementation of Primary Health Care and Uganda’s minimum health
care package. In addition, we developed a positive attitude towards working in rural/community placements.
We also provided health care at the host health facility, which was associated with many experiences in delivering
health services to patients/clients.
PROBLEM ANALYSIS/CHALLENGE IDENTIFICATION

Environment scanning/community diagnosis
Transect walk
The transact walk was done on 16th June, 2019 from 3:00pm to 6:00pm with the guidance of the VHT,
Ms. Kenema Grace, from Kamuganguzi village to Kyonyo trading Centre. We also reached katuna.
During the walk, we came to know where Kamuganguzi Health Centre III is located, and some of
economic activities carried out in the community, that is, animal farming, crop growing, stone quarrying.
The water sources, schools, shops, trading Centres, churches and mosques were located.
Unfortunately, there was some open defecation along some roads and the water sources were neither
clean nor protected.
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Drawing of transact walk.
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Review and analysis of health records at Kamuganguzi HC III
From 18th June, 2019 to 20th June, 2019, the health records of various departments at the health facility
for the past 6 months were reviewed. The departments included; Out Patient Department [OPD],
Antenatal Care [ANC], Antiretroviral Therapy [ART], Mother and Child Health [MCH], In patient
Department [IPD], maternity, laboratory. The data was analyzed and some presented as below;
Most causes of mobidity in Kamuganguzi in past 6 months

age Dec, Jan, Feb, March, April, percentage
Disease May,2019 total
group 2018 2019 2019 2019 2019 (%)
>5years 96 98 81 128 8 18 429 12.1
Diarrhea
<5years 11 13 25 13 22 22 106 13.7
>5years 216 166 196 327 206 244 1355 38.2
RTI
<5years 69 29 36 78 90 162 464 60.2
>5years 15 12 10 13 2 7 59 1.7
Worms
<5years 3 3 6 8 2 0 22 2.9
>5years 23 23 31 75 28 37 217 6.1
UTIs
<5years 1 2 0 10 1 0 14 1.8
OPD >5years 651 560 370 728 679 555 3543
attendance <5years 151 101 54 130 188 147 771
Source: OPD register
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% of Some Diseases in kamuganguzi
60.2
38.2
13.7
12.1
6.1
1.7 2.9 1.8
>5YEARS <5YEARS >5YEARS <5YEARS >5YEARS <5YEARS >5YEARS <5YEARS

DIARRHEA RTI WORMS UTIS
Source: OPD register.
Immunuzation trend for past 6 months

Vaccine dec ,2018 jan, 2019 feb, 2019 march, 2019 april, 2019 may, 2019 Total
rotavirus ,1 &2 176 122 77 58 70 116 619
DPT 1 53 35 53 51 36 54 282
DPT3 51 57 55 52 44 50 309
Measles 49 65 51 32 23 32 252
TT in pregnancy. 59 119 91 96 72 108 545
BCG 42 28 55 30 25 45 225
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% OF FAMILY PLANNING
USAGE
percentage (%)
60
22.0 18.0
LONG TERM FP ORAL INJECTABLE
Source: MCH data records (family planning register)
Antenatal visits
dec jan, feb,
,2018 2019 2019 march, 2019 april, 2019 may, 2019 total
ANC 4th visit 19 39 19 27 38 47 189
ANC 1st visit 51 66 70 56 47 58 348
total ANC 137 222 194 221 195 221 1190
male involvement in ANC
37 37 18 43 21 28 184
% of male involvement in
ANC 27.0 16.7 9.3 19.5 10.8 12.7 15.5
% of males not involved 73.0 83.3 90.7 80.5 89.2 87.3 84.5
Maternal deliveries 27 20 34 24 28 33 166

Source: ANC register
Patient clerking at the health facility

Most patients received were out patients, and most of them presented with Respiratory Tract Infections
[RTIs], diarrhea, UTIs, alcohol intoxication.
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Key informants
Using the key informant guiding questions, the key informants, that is, health facility in-charge, VHTs,
and Health Inspector were consulted. These brought up the following views as shown in the table below;
Key informant Views

Health facility in-charge There are some cases of diarrhea; most of them are due to poor sanitation.
There are low early antenatal visits at the facility; this is mostly due to the culture of
the community members where they believe that they should only go to the health
facility when they are really sick.
The Respiratory Tract Infections [RTIs] are mainly seasonal; they occur most
during dry seasons.
VHTs The level of sanitation of the community is still poor; few hand washing facilities,
with few latrines, the few latrines are in poor conditions, few latrine covers, few
latrine shutters, no drying racks, and open defecation.
There is frequent RTIs which are related to climatic changes, poor feeding. there is
high prevalence of HIV.
There are high skin infections mostly in children; related to poor hygiene.
Health Inspector (Ms. There are very few latrines (76%) relative to the homesteads (where people claim
Tusiime Dativa) that they don’t have enough space, men are less active and spend most time in
bars)
Dirty latrines (caused by lack of ownership where most homes share the few
latrines)
There are very few hand washing facilities
There is no boiling of drinking water
Focus group discussions

We did two focus group discussions using the guiding open-ended questions [see appendix]. The first
was made up of 10 members and it was conducted at the health facility. It included 5 men [3 married,
and 2 single] and 5 married women and it took about 20 minutes while recording the conversation. The
second focus group discussion was made up of 8 members [5 married women, and 3 married men] and
it lasted for over 30 minutes while as well recording the conversation; it was held at the VHT-Kenema
Grace’s home. From these focus group discussions the major health problems in the community were;
diarrhea, Common colds, skin rash, HIV.
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Home visits
From 17th June, 2019 to 20th June, 2019, home visits were done in 70 homes with the guidance of the
VHTs to identify the health challenges in the community. Observation method with help of checklist [see
appendix] were used and the following information about the homes was obtained;
Table showing the coverage of various items in homes of 70 households visited;
ITEM NUMBER PRESENT / PERCENTAGE

FREQUENCY COVERAGE
Hand washing facilities 2 3%
Latrines 53 76%
Latrine covers 11 16%
Latrine shutters 18 26%
Drying racks 17 24%
Rubbish pits 6 9%
Drinking water treatment 43 61%
(boiling water)
Open defecation 43 61%
Immunization 53 76%
Pit latrine cleanliness 21 30%
Community dialogue meeting.

A community dialogue was held on 29th June,2019 at the chairman LC1 ‘s place from 3:00pm to 6:00pm
which was attended by community members, local council leaders like chairman LC1, Gomborora
Internal Security Officer [GISO], health workers, and VHTs. We began by an opening prayer then
introduced ourselves to the community and later we revealed the results from the data review and home
visits. The results included; the common diseases recorded at the health facility like Respiratory Tract
Infections [RTIs], diarrhea, Urinary Tract Infections [UTIs], low early antenatal attendances among
others; and our findings about good sanitation from the visited homes which included almost no hand
washing facilities, few latrines, very few latrine covers and shutters, poor latrine cleanliness, some cases
of open defecation, few rubbish pits.
The community members told us about the health challenges they face. These included; diarrhea, HIV,
Common cold, skin rash, skin infections, allergies. They also complained about the absence of an
ambulance at the health facility, some disciplines like dental surgery not being represented at the health
facility, lack of ultrasound scan, and lack of some medicines at the facility. Some of these complaints
were cleared by reminding the community members that Kamuganguzi Health Centre is a health Centre
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III and it can’t have some of the above mentioned services; such services can be found at kabale
regional referral hospital.
We agreed with the people that from the findings of the home visits, there were contributing factors to
diarrhea. Most community members agreed with us to build new latrines, establishing hand washing
facilities (tippy taps), make latrine shutters and covers, improving latrine cleanliness, avoiding open
defecation, dig rubbish pits, and clean water sources (springs). The community members even told he
team to move through the village the following week as we help those who could not make tippy taps,
latrine covers, latrine shutters.
Challenge prioritization
Challenges that were contributing to diarrhea were found out and they were represented in a challenge
priority matrix. Using the challenge priority matrix, we chose the priority challenge as follows.
CRITERIA PRIORITY CHALLENGES

(RATE from 1 to 3) Very few Very few latrine Very few latrine Few latrines
hand covers shutters
washing
facilities
Time to implement. 3 3 2 1
(1=most time
3=least time)
Contribution to 3 2 2 1
diarrhea
(1=least contribution
3=most contribution)
Cost to implement. 2 2 1 1
(1=most cost
3= least cost)
Sustainability. 3 2 2 2
(1=least sustainable
3=most sustainable)
Capacity to 3 3 1 1
implement
(1=least available
3=most available)
TOTALS 14 12 8 6
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From the challenge priority matrix above, “very few hand washing facilities” was chosen as our
priority challenge. However, other challenges like few latrines, few latrine covers and shutters were also
addressed.
Root cause analysis – the fish bone and 5 whys technique

The root causes of the current situation were analyzed using both the fish bone diagram and the five
whys technique.
The fish bone technique

POLICIES
1. Few policy enforcers to PROCESS AND PROCEDURES

ensure that hand
washing facilities are in 1. The procedures of making
place. tippy taps are quite
2. Reluctance in policy different and are not
enforcement. known to most people.
3. Health facilities mainly
provide curative care
than preventive.
Current
situation
Of the 70 households sampled

in Kamuganguzi village, only 2
[3%] have hand washing
facilities
PEOPLE
1. Ignorance about the ENVIRONMENT

benefits of hand washing.
2. Insufficient skills to 1. Stony and hard ground
establish hand-washing which makes it difficult
facilities. to construct firm tippy
3. Stealing of the jerrycans taps.
of the tippy taps.
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The five whys technique
Current situation: Of the 70 households sampled in Kamuganguzi village, only 2 (3%) have
hand washing facilities
The “why” question Response
Why are there very few hand washing facilities Because community members have low
in kamuganguzi village? knowledge and inadequate skills of the
community on how to make hand-washing
facilities
Why do the community members have low Because they have not been told and
knowledge and inadequate skills of the demonstrated to on how to make hand
community on how to make hand-washing washing facilities with the benefits thereof.
facilities?
Stakeholder analysis- interests and concerns

The individuals who had a stake in our project were analyzed using the stakeholder analysis sheet as
shown below;
Stakeholder group What are they most What is their What do we need to do to
or individual interested in? biggest concern? get their support?
Facility in-charge Leaving a sustainable Quick and better To be disciplined; time
health-related positive health service management at the heath
impact in the delivery. facility; respecting her.
community.
Providing health
services at the facility.
VHTs Maintaining awareness A healthy community. Cooperation with them.
about health related
issues in the
community.
Kabale district A healthy and Advocating for good Official communication to
authorities, that is, productive community. health. them.
District Health Officer Working together with them.
[DHO], Chief
Administrative Officer
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[CAO], Health
Inspector, Town council
mayor, Chairman LC1.
Team members Improving the health of Health of the Commitment and team
the community. community. work;
MUST community Creativity and Learning leadership Effective communication

health department and innovativeness of the skills. with them.
MUST supervisor. students. The students’ Cooperation with them.
wellbeing.
Community members Our health skills and Their health and Effective communication.
services. wellbeing. Respecting them.
Community health.
Prioritizing Actions
The priority actions towards addressing the very few hand washing facilities-the priority challenge, were
examined using a priority matrix. However, it doesn’t mean that the priority action that was rated highest
was the only thing that was done, but rather, much emphasis was put on it and as well other priority
actions were tackled.
Priority matrix
CRITERIA PRIORITY ACTONS
(RATE from 1 to 3) Sensitization of Demonstration Demonstrations for Constructing
the community to VHTs on hand-washing hand-washing
about the making hand- facilities in the facilities in
relevance of washing community sampled
hand washing. facilities homesteads.
Time to implement. 3 3 3 2
(1=most time
3=least time)
Cost to implement. 3 3 2 2
(1=most cost
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3= least cost)
Potential for 2 3 3 2
improving quality in
the long-term.
(1=least potential
3=most potential)
Capacity to 3 3 3 2
implement
(1=least available
3=most available)
TOTALS 11 12 11 8
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THE CHALLENGE MODEL
MISSION
To improve the health of the community by increasing hand washing facilities as preventive measure
against diarrheal diseases.
VISION
A healthy Kamuganguzi community free from diarrheal diseases.
MEASURABLE RESULT:
Increased handwashing facilities from 3% to 40% in Kamuganguzi village within three weeks.
OBSTACLES AND ROOT CAUSES PRIORITY ACTIONS

1. Ignorance about the benefits of
hand washing. 1. Sensitization of the
2. Insufficient skills to establish community about the
hand washing facilities. relevance of hand
3. Stealing of the Jeri cans of the washing.
tippy taps. 2. Demonstration to VHTs on
4. Stony and hard ground which
makes it difficult to construct
making hand-washing
firm tippy taps. facilities
5. Few policy enforcers to ensure 3. Demonstrations for hand-
that hand washing facilities are washing facilities in the
in place. community
6. Reluctance in policy
4. Constructing hand-
enforcement.
7. Health facilities mainly provide washing facilities in
curative care than preventive. sampled homesteads.
8. The procedures of making tippy
taps are quite different and are
not known to most people.
CURRENT SUTUATION:
Of the 70 households sampled in Kamuganguzi village, only 2 [3%] have hand washing
facilities
CHALLENGE:
How will we increase the handwashing facilities from 3% to 40% in Kamuganguzi village
despite the low knowledge and inadequate skills of the community on how to make hand-
washing facilities?
Page 22
ACTION PLAN
Description of the interventions (priority actions) to deal with the challenge by

stake holder.
The priority actions we did aimed at achieving the measurable result, that is, ‘Increased handwashing facilities
from 3% to 40% in Kamuganguzi village within three weeks’. These included;
1. Sensitization of the community about the relevance of hand washing.
2. Demonstration to VHTs on making hand-washing facilities
3. Demonstrations for hand-washing facilities in the community
4. Constructing hand-washing facilities in sampled homesteads.
Procedure of making a tippy tap.

Requirements: Two strong poles of 1.5m length, two strong sticks (horizontal bar and pedal) of 1m
length, 2 nails, a hammer, a panga, a hoe, gravels, 3litre or 5litre jerry can with a cover, nylon gauze
2m long, clean water, soap.
Procedure:
Take measurements of the poles, sticks, nylon gauze as per the above requirements, dig two holes
each 30cm deep and 70cm apart using a hoe with/without help of a panga.
Place the strong poles one in each hole, fill the hole with some gravels then with soil to increase firmness
of the standing strong poles.
Drill a hole 5cm below the mouth of the jerrycan anteriorly and opposite to the handle using a nail and
hammer/stone through which water will pass. Drill a second hole at the handle top for free air exit when
in use of the tap.
Drill a hole in the Centre of the jerrycan cover using a nail and hammer/stone, pass the nylon gauze
through the hole and make a knot on the inner surface of the cover to prevent the gauze from getting
off the cover. Fill the jerrycan with water up to the level of the anterior hole, cover the jerrycan and
ensure that the gauze is firm onto the cover.
Pass the horizontal bar through the jerrycan handle and then place the horizontal bar over the two
strong poles. To the hanging end of the nylon gauze, tie the pedal stick at its tip, 15cm above the ground.
Cut off the remaining nylon gauze, drill a hole through soap using a nail, pass the gauze through the
hole then tie the soap to stay held within the gauze, tie the free end of the gauze on the horizontal bar
with the soap hanging freely.
Dig a ditch (shallow and wide) directly below the jerrycan, guided by the stream of water flow from it,
then fill the ditch with gravels to avoid a mud-lodged area following hand-washing.
Page 23
Use the tippy tap by stepping on the pedal, wet the hands, use the hanging soap, rub hands together
and between the digits, rinse and dry the hands, remove your foot from the pedal. Always refill the
jerrycan via the mouth, replace the soap whenever it is over.
However, we not only worked on hand washing in kamuganguzi village but we also did the following;
1. Demonstration and construction of latrine covers and shutters in the community.
2. We also encouraged the community to construct more new latrines in order to prevent open
defecation.
3. We also encouraged the community to regularly clean their water sources, the springs.
4. We encouraged the community to take their children for full immunization at the health facility
and to treat drinking water [by boiling it].
5. We encouraged some homesteads to construct drying racks for their plates, in case a
homestead lacked one.
6. Health education talk in kamuganguzi Janan Luwum memorial secondary school where we
sensitized the students about good personal hygiene (cutting nails, bathing often, washing and
ironing cloths, brushing teeth after every meal), good sanitation (cleaning the compound,
washing hands after visiting the latrines/toilets and before eating), UTIs, HIV [prevalence in the
area, mode of transmission, risk factors, effects of HIV infection-opportunistic infections, and
ways of preventing HIV infection], safe male circumcision.
Table Showing Action Plan

CHALLENGE: INDICATORS:
How will we increase the handwashing facilities from 1. Percentage of homes with hand washing
3% to 40% in Kamuganguzi village despite the low facilities.
knowledge and skills of the community on how to
make hand-washing facilities?
MEASURABLE RESULT:
Increased handwashing facilities from 3% to 40% in
Kamuganguzi village within three weeks
PRIORITY ACTIONS:
1. Sensitization of the community about the
relevance of hand washing.
2. Demonstration to VHTs on making hand-
washing facilities
Page 24
3. Demonstrations for hand-washing facilities
in the community
4. Constructing hand-washing facilities in
sampled homesteads.
ACTION PERSON(S) START DATE END DATE RESOURCES
RESPONSIBLE
Transact walk Team members 16th/06/2019 16th/06/2019 Time, guide.
Meeting stake Team members 18th/06/2019 25th/06/2019 Time, venue, chairs
holders
Review of data at Team members 18th /06/2019 20th/06/2019 Time, data registers, data
health facility clerk.
Community Team members 17th/06/2019 20th/06/2019 Time, questionnaires,
diagnosis; guide,
observation, home
visits, focused
group discussions.
Data analysis Team members 24th/06/2019 25th/06/2019 Time, computer,
calculators.
Community Team members, 29th/06/2019 29th/06/2019 Time, manila papers,
dialogue about chairman LC1, markers
good health, and VHTs
demonstration of
handwashing
facilities, latrine
covers, and
shutters.
Construction of Team members 1st/07/2019 5th/07/2019 Time, poles, Jerry cans
handwashing and VHTs. (3l, or 5l), nails, wire
facilities (tippy gauze,
taps),and latrine
covers in
homesteads
Conduction of a Bweyagera James 8th July,2017 8th July,2019 Time
health education
talk in
Kamuganguzi
Janan Luwum
Page 25
memorial
secondary school
Evaluation; Team members 10th July,2019 13th July, 2019 Time,
examination of the
effects of our
interventions in the
community
Report writing Gobera Boaz 1st July,2019 14thJuly, 2019 Time, computer
Dissemination of Team members 13th July, 2019 13th July, 2019 Time, charts, markers,
results to the venue
community
members, VHT,
and Chairman LC1.
Dissemination of Team members 15th July, 2019 15th July, 2019 Venue, time, computer.
final results to the
heath facility staff.
Comments on how implementation of the plan went by the team

1. The implementation was easy since the community members were cooperative and ready to learn.
2. We were guided by the VHTs in the various homes very well.
3. The project was owned by the community members who even pledged to join the VHT during follow-up
of other households, without a handwashing facility.
4. The implementation was timely in that it required resources that were easily accessible and this
basically made us to be in position to reach out many homes during the implementation
5. There was active participation by the team members and community
6. Community members embraced and appreciated the project thus active participation was attained to the
peak.
EVALUATION
Evaluation was done for 4 days by the team members, with help of the VHT. Before intervention, 2[3%]
of the 70 homesteads sampled in kamuganguzi village had a hand washing facility at the latrine. -
After intervention, 33 [47 %] of the 70 sampled homesteads in Kamuganguzi Village had hand-washing
facilities at the latrine. Every household which had / constructed a hand-washing facility, we urged, and
sometimes helped, them to construct a latrine cover, latrine shutter and to construct a pit latrine for
Page 26
those who did not have pit latrines. In addition, some water sources (springs) were cleaned immediately
after the community dialogue meeting.
In addition, the chairman LC1 constructed a pit latrine and three other pit latrines were still being
constructed by the time we left the community.
LIMITATIONS
During our community placement at Kamuganguzi Health Centre III, we faced a number of limitations which
include;
1) Language barrier; team members who did not know how to speak the local language –Rukiga- found it
difficult to communicate effectively with some community members which restricted them from expressing
their ideas and views, especially during sensitization and health education talks.
2) Inaccessibility of some stake holders (community members); some of the stake holders were inaccessible
in time of need, which caused delays during some project activities because they usually spent most of
their time taking care of their gardens till late evenings and this made it hard to access them during week
days.
3) Hilly terrain: Most of the households were located up in the hills and we had to climb there yet some group
members got difficulties and easily got tired before we could cover enough homesteads.
4) Limited time: Some households were not evaluated because time was not enough to do so.
COMMENTS ON THE PLACEMENT BY TEAM MEMBERS

a. The placement site is hilly.
b. The placement site is cold around 12oC in the morning and 16oC in the evenings.
c. Positive attitude of different stake holders; the facility staffs, local leaders, VHTs and community
at large, were interested in our project and gave us the necessary support to make it a success.
d. Cooperation; we were able to exhibit team work in all the planned activities like scanning,
mobilization, sensitization, implementation, this enabled us to carry out most the planned
activities successfully.
e. Communication; for effective communication, the local language (Rukiga) was used during our
sensitization and awareness meetings in the villages except in schools (Kamuganguzi Janan
Luwum memorial secondary school) where English was used.
f. To some extent, the placement program was fun where we were able to reach Katuna boarder
and Lake Bunyonyi.
Page 27
CONCLUSION
We successfully carried out community sensitization in Kamuganguzi village where we managed to raise the level
of awareness about the relevance of a hand washing facility in a homestead, how to locally construct a standard
hand washing facility from local resources.
We also managed to successfully raise the number of households with standard hand washing facilities in
Kamuganguzi village from 3% to 47% within three weeks.
Other than hand washing, we were also able to do the following during the placement; PHC activities, like, cleaning
of water sources; health education talk in Kamuganguzi Janan Luwum memorial secondary school and taught the
students about HIV, UTIs, sanitation, personal hygiene and so on; latrine covers and shutters.
RECOMMENDATIONS
 We recommend that the Health Inspector comes up with policies to ensure that sanitation standards are
not in any way compromised.
 We also recommend that, the health inspectors and health assistants attached to different health facilities
make it a priority to focus on sanitation issues directly affecting the community.
 We recommend that the LC1 Chairpersons in conjunction with the VHTs should ensure continuous
sensitization of the community about the need to always wash hands after toilet/pit latrine visit and also
have a fully functional and standard hand washing facility at the right location.
 In addition, time allocated for the placement should be increased to give students time to implement and
evaluate their projects.
 We recommend that the village security team comes up with by-laws to ensure there is safety of the jerry
cans of tippy taps, for example, anybody found stealing a jerrycan should be given a certain penalty like
buying more 10 jerry cans.
Page 28
APPENDIX
Check list
CHECK LIST
DEMOGRAPHIC INFORMATION
SEX Male …………..Female…………….. AGE………… Household……………….
RELIGION……………………………………………MARITAL STATUS……………………………
HOUSEHOLD HEAD: Man Woman Education Level………………………..
OTHER INFORMATION
a) PIT latrine Present Absent

i) General condition good Poor
ii) Cleanliness clean Dirty
iii) latrine cover present Absent
iv) hand washing present Absent
facility
If present functional Non functional
v) shutter present Absent
b) drying rack present Absent
If present is it functional? yes no
c) rubbish pit present absent
If present, is it functional yes no
d) i) drinking water present absent

vessel
If present, is it yes no
functional?
ii) method of drinking ………………………………………………..
water treatment
(specify)
e) immunization status
i) are there children yes No
below 5 years?
If yes, check immunization
status for each (check e-card)
Fully immunized Not fully immunized
If not, why? No vaccine Did not mind
Page 29
Questionnaire
MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY
FOCUS GROUP DISCUSSION QUESTIONS

(Client should be told to fell free because this information will be kept confidential)
1. What are the commonest health problems in the community?

…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………….
2. Have you ever visited the health facility?

…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………...
3. What was the problem that made you to visit the health facility?
…………………………………………………………………………………………………………………………
……………………………………………………………………………………………………
4. What do you think the cause was?
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………..
5. Have you ever had diarrhea, and how often?
…………………………………………………………………………………………………………………………
…………………………………………………………....................................................
6. How many times have you experienced diarrhea?
……………………………………………………………………………………………………………….
7. What do you think could have been the cause?
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………..
8. Did you visit the health facility?
…………………………………………………………………………………………………………….
9. Were you helped at the health facility and how?
………………………………………………………………………………………………………………
10. Do you think you can do anything to prevent diarrhea and what is it?
…………………………………………………………………………………………………………………………
……………………………….……………………………………………………………………
11. What do you think the facility could do to prevent diarrhea?
…………………………………………………………………………………………………………………………
……………………………………………………………………………………………………
12. Are you aware of rotavirus vaccination, and have you ever taken your children for this
vaccination?
.............................................................................................................................................
END
Page 30
Pictorial
Group photo with our must supervisor. From left to right: Agaba Amon-PHS; Bweyagera
James-MBChB; Muhumuza Apolo-MLC; Abaho Anthony-BSP; Ms. Owokuhaisa Judith-
MUST Supervisor; Gobera Boaz-PHA; Atukunda Prosper-MMLC; and Twongyeirwe
Doreen-BNC.
Page 31
Community dialogue meeting about healthy life.
Health talk at Kamuganguzi janan luwum memorial S.S [left photo]; after which
we individually mate some of the students who had some health issues and we told
them the treatment and preventive measures [right photo].
Page 32
Team members going to the community for implementation
Team members, VHT, and community Latrine shutter made by team members
members making a latrine shutter
from banana reeds, sticks and ropes.
Page 33
Community member being helped (by the Team member improvising for a hand
team members) to make a tippy tap washing facility without using a Jeri
can but with a bottle
Even a child being taught the One of the pit-latrines found in construction
relevance of and how to use a tippy process during evaluation
tap.
Page 34
Dissemination meeting to the community members, the
chairman LC1, and VHT-Anah
Dissemination meeting to the health facility in-charge, facility nurse, and health
inspector.
Page 35

Increasing Hand Washing in Kamuganguzi

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MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY

INCREASING HAND WASHING FACILITY COVERAGE IN KAMUGANGUZI VILLAGE AS A

BWEYAGERA JAMES 2015/MBR/025

Signature: …………………………………….. Date: ……………………………………

MUST SUPERVISOR (Ms. Owokuhaisa Judith)

Check list ......................................................................................................................................................... 29

“A healthy Kamuganguzi community free from diarrheal diseases”

PROBLEM ANALYSIS/CHALLENGE IDENTIFICATION

Most causes of mobidity in Kamuganguzi in past 6 months

>5YEARS <5YEARS >5YEARS <5YEARS >5YEARS <5YEARS >5YEARS <5YEARS

Source: OPD register.

Immunuzation trend for past 6 months

LONG TERM FP ORAL INJECTABLE

Source: MCH data records (family planning register)

Maternal deliveries 27 20 34 24 28 33 166

Patient clerking at the health facility

Key informant Views

Focus group discussions

Table showing the coverage of various items in homes of 70 households visited;

ITEM NUMBER PRESENT / PERCENTAGE

Community dialogue meeting.

CRITERIA PRIORITY CHALLENGES

Root cause analysis – the fish bone and 5 whys technique

The fish bone technique

1. Few policy enforcers to PROCESS AND PROCEDURES

Of the 70 households sampled

1. Ignorance about the ENVIRONMENT

Stakeholder analysis- interests and concerns

MUST community Creativity and Learning leadership Effective communication

OBSTACLES AND ROOT CAUSES PRIORITY ACTIONS

Description of the interventions (priority actions) to deal with the challenge by

Procedure of making a tippy tap.

Table Showing Action Plan

Comments on how implementation of the plan went by the team

COMMENTS ON THE PLACEMENT BY TEAM MEMBERS

SEX Male …………..Female…………….. AGE………… Household……………….

HOUSEHOLD HEAD: Man Woman Education Level………………………..

a) PIT latrine Present Absent

d) i) drinking water present absent

MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY

FOCUS GROUP DISCUSSION QUESTIONS

1. What are the commonest health problems in the community?

2. Have you ever visited the health facility?

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