Short Communication Use of group maturity index to measure growth, performance, and sustainability of community health clubs in urban water, sanitation and hygiene (WASH) program in Zimbabwe

Zimbabwe experienced an unprecedented cholera outbreak in 2008 and 2009. Reduced access to water, sanitation and hygiene, delayed community health education, and limited knowledge on cholera prevention were the major risk factors of this outbreak which were addressed by urban WASH interventions. Health and hygiene promotion through community health clubs (CHCs) is a cost-effective strategy to reduce the risk of cholera. In 2013, UNICEF Zimbabwe launched the Small Towns WASH Program (STWP) and used the CHC approach for hygiene promotion. To monitor the growth, performance, and sustainability of CHCs, STWP employed the Growth Maturity Index, which measures the status of CHCs in ﬁ ve domains: objectives, governance, resources, group systems, and impacts. This study described the maturity status of CHCs as measured by GMI as a new monitoring tool and assessed if CHCs ’ performances in GMI ’ s output domains are associated with the impact domain. The results suggested that over 75% of CHCs had reached the managed stage or the mature stage by 2018. Three of the GMI ’ s output domains were independently associated with the overall impact domain after controlling for potential confounders. CHCs and club members may experience overall positive impacts by developing their governance, resource, and group system domains.

• This study demonstrated the potential utility of GMI as a useful monitoring tool to assess the growth, performance and sustainability of community health clubs.

INTRODUCTION
Cholera is an infectious disease caused by a bacterium One potential strategy to reduce the risk and spread of cholera is health and hygiene promotion through community health clubs (CHCs). The CHC approach is based on behavior change theories (e.g., Health Belief Model, Social Learning Theory) and provides a platform for community members to enhance their knowledge and selfefficacy to achieve healthy behaviors through peer support and reinforcement (Rosenstock et al. ). In Zimbabwe, CHCs have been field-tested and implemented mainly in rural districts since 1994 (Waterkeyn & Waterkeyn ).
Previous studies highlighted that CHCs are cost-effective and contribute to improving sanitation and hygiene prac- Although CHCs have been recognized as a useful intervention for health and hygiene promotion, a recent cluster randomized controlled trial in Rwanda reported that CHCs had no effect on a child diarrhea outcome despite some improvement in sanitation practices (Sinharoy et al. ). A process evaluation of this intervention highlighted low program fidelity due to various contextual factors (e.g., limited CHC monitoring conducted to comply with a research timeline) as a plausible reason for the limited impact on health outcomes (Waterkeyn et al. ). Moreover, CHC's effects on health outcomes may not be observed within a short period of time and require a more realistic timeline (Waterkeyn et al. ). It is therefore of vital importance to monitor CHCs over time to overcome any issues with program implementation for CHC sustainability and potential health benefits.

GMI approach
The GMI tool measures the growth or maturity status of CHCs in five domains: objectives, governance, resources, group systems, and impacts. The first four domains focus on output measures of CHC development while the last domain addresses the outcomes. These domains were selected to monitor CHCs' capacity to sustain their activities with clear goals, management structures and systems, financial resources, and positive outcomes even after the STWP implementation period. Each GMI domain includes several topics to provide insights into what aspect of CHCs can be further developed (see Figure 1).

GMI domains
The objective domain includes the rationale and process of interaction with stakeholders, and monitoring activities. The impact domain includes the status of achievement of objectives, benefits, satisfaction with the club, attendance rates to club meetings, group savings, group resilience, perceived difference between club members and non-members, and project innovation and diversification. Additional background of GMI tool was described elsewhere (Cole et al.

Data collection
GMI data collection took place in 2018 through a group survey with CHC members as part of STWP program monitoring. A structured questionnaire was employed to assign a score to each element or topic of GMI domains with a fivepoint Likert scale. For each question, participating CHC members had a discussion if necessary and provided one response as a club. The assignment of score was conducted by enumerators from Non-Governmental Organizations (NGOs) and local authorities who received training for data collection and standardized scoring. The sum of scores for GMI domains was calculated as index scores.

Data analysis
Index scores were subsequently converted to a percentage to classify each club into four maturity stages: infancy stage (0-39%), growth stage (40-59%), managed stage (60-89%), and mature stage (90-100%). For example, the group system domain includes four topics, and the highest score for the domain would be 20 if a community health club scores the maximum of 5 points in each topic. The percentage was calculated by dividing the summed scores by the possible highest score for each domain. In this example, it would be 100% by dividing 20 (summed scores) by 20 (possible highest score). By using this approach, we estimated the maturity stage of CHCs for each GMI domain and the GMI as a whole.
In total, data for 158 clubs in 13 towns were available for analysis. Data for Hwange town were not available, and four clubs were removed from analyses due to insufficient data for many variables. Univariate analyses were conducted to describe the number of health clubs by project towns, year of establishment (e.g., 1 ¼ before 2012, 2 ¼

Ethical approval
This study analyzed secondary data, which did not include any personally identifiable information or individual data.
The primary purpose of GMI data collection was to monitor STWP implementation. In accordance with the ethical requirements for human research in Zimbabwe, this study was not required to obtain a formal ethical approval. Table 1    suggests that the majority of CHCs successfully moved from the infancy stage to a higher maturity stage. Governance, resource, and group system domains were

DATA AVAILABILITY STATEMENT
Data cannot be made publicly available; readers should contact the corresponding author for details.