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Communication framework during cholera outbreaks

Annex to the:

Toolkit E – Tanzania Hygiene Communication in Emergencies Guidelines (final draft, 2010) and

Toolkit F - WASH guidelines for cholera prevention, preparedness and control (final draft, 2010)

Part of the:

Water, Sanitation and Hygiene (WASH) Emergency Preparedness and Response ToolkitsFor use on the Mainland and in Zanzibar, United Republic of Tanzania

(Acknowledgements at the end of the document)

Annex 1 - Communication framework during cholera outbreaks

Key questions Summary of understanding so far

What are people (examine different groups) doing that presents a risk to hygiene and public health? (See more detailed assessment checklist)

Relatively high coverage of latrines (approx. 70%). Low coverage and use of improved latrines & the majority do not have handwashing facilities. Low prevalence of handwashing with soap in adults and children. Drinking water sources not protected. Water from water vendors not clean. Water is not stored or drawn safely at home. Children’s faeces are not seen as dangerous Leftover food not reheated thoroughly and fruits are not washed. Fruit juices and ice-lollies use contaminated water. Poor hygiene amongst food sellers /cooks Communal gatherings - food is not prepared hygienically Washing of deceased cholera patients leads to further transmission. People scared to disclose sickness or death Indiscriminate refuse disposal causes tips that are breeding grounds for flies Delay in seeking treatment

What feasible priority actions or practices are required to protect their health?

Handwashing with soap at key times Treating drinking water by boiling, use of chlorine / WaterGuard or other treatment method ORT (ORS, zinc, other liquids and feeding) especially for children Using /digging latrines or improving latrines by adding handwashing facilities? Safe disposal of children’s faeces Reheating food until hot Cover food Seek treatment early, take liquid on the way Report cases and deaths and get professional help for the burial

What are the key obstacles that make these practices difficult or prevent people from taking action? (As they see it)

They believe that cholera is caused by witchcraft Do not believe that proposed solution will make a difference They do not think that children’s faeces are harmful They do not like the taste of boiled or chlorinated water Fear that they will not be allowed to bury their loved ones properly

What motivates people who already practice the (Assessment to be carried out)

Key questions Summary of understanding so far

desired behaviour? (Doers and non doers)

What are the different primary target or audience groups?

Mothers with young children, older women, men, school children, youths, water vendors, food vendors, people with disabilities

Who might influence the primary target groups? (Family members, friends or change agents e.g. celebrities, sports personalities, teachers etc.)

Traditional leaders, traditional healers, TBAs,

What might influence these different target groups?

(E.g. nurture, disgust, affiliation, convenience etc.)

Mothers like to feel they are doing the best for their children. Fathers like to feel they are protecting their family. No one likes to think they might be eating shit

What are the trusted methods of communication used by the different target groups? (Ask who do you go to for advice)

Older women/TBAs Radio, CORPs, Street Government,

What methods of mobilising communities are available (e.g. strong leadership, religious institutions, women’s groups, social networks, local NGOs etc.)

Religious leaders, PHAST extension workers?

What outreach workers are available? TRCS volunteers, CHWs, TBAs

What else can be done to enable men, women and children to take action? (E.g. provision of WASH facilities, distribution of hygiene items or household water treatment technologies)

Mass distribution of soap or chlorine?

Functioning hand-washing stations next to public latrines?

What advocacy initiatives are required at the national or local level?

Need for more environmental health workers? Authorities to be held responsible for producing cholera plans? Increased/ more timely funding for cholera response?

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Aim: To ensure that men, women and children are given information on how to protect themselves from cholera and are mobilised to take action to reduce the risk of cholera

Objectives: Define objectives for each different target group

Indicators: Select 3 indicators ONLY based on priority actions outlined below. For example:

At least 25% increase in hand-washing after defaecation and before preparing or eating food, within 4 months (in target group).

At least 25% increase in use of HHWTSS, (household water treatment and safe storage) within 4 months (where promoted)

At least 25% increase in knowledge of 3 key actions to prevent cholera, within 4 months in target group

Target Group Key messages /concepts/actions desired Communication methods & locations

Communicators/ person responsible

Primary Target Audience1

The primary target audience is at the heart of your communication efforts. The success of the hygiene communication will be measured by change or action in this group.

General Community General information in fact sheet:

Cholera is spreading through consumption of contaminated food or water / made dirty by vibrio cholerae.Normally the disease is spread by not observing sanitation and hygiene principles.Absence of clean environment or a sick person contaminates water and food, in that way spreads disease to others who use that water or food. 1. Signs and symptoms of cholera

2. Mode of transmission

3. Location of treatment centres

4. Preventative & control measures: see below (personal hygiene, food, water, environmental sanitation & hygiene, home based care with ORS / fluids/ funeral safeguards)

Household information and leaflets/fact sheet

Information provided in mosque, church etc.

Information provided at community meetings, markets, bus station, bars and clubs, clinics etc.

National and local radio spots

Newspapers

Musical events

Mobile video units (note – could use experience of people severely affected by cholera in Pemba to prepare a video to influence others)

Community based volunteers (e.g. CORPs, Red cross volunteers)

Shehias, religious leaders, Imams

Community leaders and committee members

Water user associations

Name radio stations and contacts

1 The messages for the primary target audience were compiled by an interagency working group in response to the cholera outbreaks in 20104



a. Do not drink local brew during cholera outbreak

b. Do not hide a patient with cholera symptoms – take him/her immediately to the treatment centre

Your health is in your hands – wash your hands with soap and flowing water:

1. After helping someone who is sick

2. After visiting/using toilet

3. After touching child’s faeces (after cleaning child’s bottom)

4. Before eating and feeding a child

5. Before preparing/cooking food

6. Before breast feeding your child

Gatherings are contributing to spread of cholera

1. Avoid gatherings during cholera outbreak

2. It is not allowed to eat or drink at any gatherings e.g. at funerals or celebrations, weddings, open markets etc. during cholera outbreak

3. Bodies of people who have died of cholera are very infectious

Public address system

Lamgambo

Mobile phones

Clinic staff/ Environmental health officers

District health committees

Mothers (of young children)

What to do if you or your child has diarrhoea and vomiting:

1. Use ORS immediately made using safe water (boiled or treated with chlorine)

2. In case you don’t have ORS drink plenty of safe water

3. Immediately go to the nearest health facility while drinking safe water on the way

4. Dirty clothes from the cholera patient should be washed in disinfectant /chlorine or boiled

Only drink safe water:

1. All drinking water should be boiled or treated with chlorine

Be very careful with food:

1. Do not eat fruits without washing: fruits should be cleaned with

Household visits

Information given by outreach workers and volunteers at women’s group meetings

Information and leaflets provided at clinic

TRCS, CHW, TBAs

NGOs, extension workers

Nurses and doctors

Religious leaders

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safe flowing water before eating

2. Food should be well cooked and eaten while hot

3. Don’t eat cold leftovers – reheat all food well

Feed your child safely:

1. A child under 6 months should be exclusively breast fed and should stay with the mother as far as she is conscious

2. Cholera does not spread by breast feeding, mother’s milk is always very safe for a child even if a mother is having cholera

3. For a child above 6 months should not be given cold food, heat it thoroughly

Your health is in your hands – keep them clean:

1. Wash your hands with soap:

After using a latrine

After cleaning child’s bottom

Before eating and before feeding a child

Before preparing food

Before breastfeeding

2. Do not wash hands in the same water / bowl

Dispose of faeces safely:

1. Use a toilet properly

2. Construct and use latrine if you don’t have one

3. If you have not completed construction of a toilet bury your faeces (child’s and adult)

4. Make sure a toilet is always clean

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Primary School Children

1. If you see a pupil vomiting and diarrhoea, immediately give ORS (mixture of salt and sugar), take him/her to the nearest treatment centre

2. Yes – as a precaution we are required to always drink safe water boiled or treated

3. Be careful with foods-don’t eat cold or open food

4. It is essential to use toilet when you are at school and at home. Toilets should be kept clean, to protect spread cholera by flies from the toilet

5. Wash hands with clean water and soap after visiting toilet or after playing and before eating.

6. You should also wash your hands if you help to feed a young child or change his/her nappy or after helping a sick person

7. No - you should not eat fruits that are not washed well

8. Don’t touch vomit, spread chlorine to protect spread of bacteria, take the patient to treatment centre while giving him/her ORS (mixture of sugar and salt) or safe water on the way.

9. Yes - you must inform the teacher as soon as possible

Include in school lessons and assembly

Information: posters / flyers on school notice boards and other prominent places

Drama

Competitions, games

Music

Children’s councils

Peer educators

Information given at parent groups

Madrassas and Sunday schools

Teachers

Environmental health staff. TRCS staff and volunteers

NGOs working with children

Shehias, religious leaders, Imams

Secondary School Children

1. As above

2. Spread the word and help protect your family and community

Leaflets, booklets

Peer educators

MOE

Food & Fruit Vendors Do not contribute to spread of cholera If your customer dies of cholera to whom will you sell tomorrow?Maintain good health of your customer

1. Clean utensils with hot water and soap

2. Keep utensils clean

3. Serve only boiled or treated water for drinking or making juices,

4. Serve hot food,

Fact sheets

Rapid orientation/training and certification system?

Environmental health officers

Market inspectors

Community volunteer

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5. Keep special hand-washing facility with soap for your customers,

6. Wash hands with soap after visiting toilet and before preparing food,

7. Prepare food in clean environment

8. Wash fruits and vegetables that are eaten raw with safe water

9. Sell unpeeled and unsliced fruits

Water Vendors Sell clean and safe water (a vendor who cares for his customers sells them safe water, sells water from safe source)1. Collect water from safe sources

2. Keep the surroundings of the water source in clean and hygienic condition, avoid haphazard spilling of water

3. Do not allow buckets or containers to be contaminated through poor drainage or putting buckets inside each other

4. Wash your hands with soap before fetching / collecting water

5. Use appropriate water storage and clean containers regularly with soap and water

6. Water containers should be cleaned regularly

7. Advise your customers to boil all water or treat it with chlorine during a cholera outbreak, as any water can be contaminated, even if it looks clean

Depending on the source:

1. Chlorinate water source & monitor the chlorine residual

Fact sheets

Rapid orientation

Public address

EHOs

Water department

NGOs

Other (i.e. identified as a result of ongoing assessment during response)

Secondary Target Audiences2

The secondary target audience is in a position to influence the primary target audience. The above message/actions/concepts will also apply to the secondary target audiences but additional messages may also be important

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Teachers 1. You can make a difference in the cholera outbreak

2. Diarrhoea and cholera are responsible for the loss of hundreds of millions of school days every year; handwashing with soap can reduce diarrheal disease by nearly half.

3. The handwashing habits you teach in school will last a lifetime.

4. You can easily include handwashing with soap in many lessons.

5. Making HW stations is a good activity for school children and can influence their families.

Teacher training and in-service education

MoE

Religious Leaders 1. You can make a difference in the cholera outbreak

2. Many religious faiths call for washing and cleanliness before prayer or during other religious rituals; only hands that have been washed with soap are truly clean.

3. The health of your congregants, particularly the children among them, is imperilled by lack of handwashing with soap.

4. One million lives could be saved each year through handwashing with soap??

Briefing/orientation /leaflets at religious conventions

Local meetings

MOHSW

Youth groups/women’s groups etc.

1. You can make a difference in the cholera outbreak

2. Spread the word on simple precautions you and your members can take

3. Handwashing with soap can reduce diarrheal disease by nearly half.

4. Include information about handwashing in your usual activities.

5. Make sure you provide handwashing facilities and use running water and soap at youth clubs or meeting venues.

MOHSW

Journalists, radio and TV producers

1. Key facts about cholera prevention and control addressing myths, beliefs and practices

2. Signs and symptoms

3. Mode of transmission

Press conferences

Media Briefings

Fact sheets

Ministry of Communication and Transport

MOHSW

Media NGOs

2 These messages are examples only and have not been ratified by the interagency working group9



4. Prevention and control measures (hand-washing WITH SOAP, latrine use, food hygiene, personal hygiene etc)

5. Treatment centres

6. Use of home based care (ORS) and fluids

7. Where to get information – Outbreaks alert / Early Warning – the MOHSW reports on outbreaks every Saturday to the radio

Website

Clinic health staff 1. Importance of hand-washing with soap at key times and after patient contact

2. Inform carers that they should disinfect their homes in all areas where there have been vomit and faeces

3. Use the opportunity of helping people to disinfect their homes to also investigate if anyone else is sick and provide information to family members and neighbours

Flip charts

Leaflets

Discussion with patients and relatives

Reminders (cues for action) e.g. posters at hand-washing points

MoHSW

Tertiary Target Audience

The tertiary target audience comprises decision makers and funders who can contribute to the success of the programme

Government Ministers Impact of cholera on your community

What you plan to do about it and what support you need

Briefing paper

Proposals

MoHSW

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WHO? WHAT is their role with regard to hygiene communication during response?

Action required now to prepare for future response?

Who will lead/co-ordinate hygiene communication efforts? (E.g. lead agency, committee, working group etc.)

RMO/RHO

DMO/DHO

ZMO

Mobilization of resources

Co-ordination

Review policies and guidelines

Supervise implementation of HIMS

Oversee emergency preparedness plans (including hygiene communication plan)

Capacity assessment

What human resources are available to communicate hygiene?

RHMT members Promote use of policies and guidelines Contribute to policy and guideline review

Convene planning and co-ordination meetings

Ensure local plans are in place

Environmental health officers Surveillance of food outlets

Supervising burials

Community education and mobilisation

Training on emergency response and update on hygiene communication

Clinic /health centre staff Hygiene education in clinics Training on emergency response and update on hygiene communication

VDC/VC Mtaa members Community education and mobilisation Training on emergency response and hygiene communication

What other ministries should be involved?

Ministry responsible for information and communication (mass media department)

Mass mobilisation and sensitization Advocacy for access to radio airtime

Ministry responsible for community development

Community sensitization and mobilization Invite to planning meetings

Ministry responsible for agriculture

Food safety Invite to planning meetings

Ministry responsible for water Safe water supply/ water user committees Involve in planning meetings

Ministry responsible for education Primary, secondary and tertiary education Involve in planning meetings

Ministry responsible for sanitation Sanitation Involve in planning meetings

What other partners should be involved?

Political leaders at ward and national level

Mobilization of resources and budget approval Training on emergency response and hygiene communication

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Convene local planning meetings

UNICEF/WHO Financial and technical support Support for government plans

TRCS Mobilization of volunteers and additional funding and resources for implementation

Collaboration with the MOHSW / MOH and others

NGOs Direct implementation where resources allow. May have networks of community volunteers

Collaboration with MOHSW / MOH and others

PSI Technical support on collaboration with mass media, mobilization of resources and funding, networks of community change agents

Collaboration with MOHSW / MOH and others

CBO/ FBOs Community mobilization Training and capacity building

Local media (especially radio stations)

Mass dissemination of information Briefings

Meetings to discuss opportunities for collaboration

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Outcome Indicators Who should monitor this? How? Tools and Resources. How often?

A 25% increase in mothers with young children washing their hands with soap at key times (after going to the toilet, cleaning their babies’ bottom, eating, breastfeeding and preparing food)

Community leaders

Community Volunteers

Field based NGOs

Clinic staff

General: Observation, discussion, questioning

Specific: Random sample questionnaire survey and FGDs

Each visit/contact

Weekly

A 25% increase in households correctly using WaterGuard to treat drinking water (where promoted)

Community leaders


Field based NGOs

Clinic staff


Specific: Random sample questionnaire survey

Each visit/contact

Weekly

A 40% increase in households who can list 3 key ways to prevent the spread of cholera (if your objective is to provide information)

Community leaders


Field based NGOs

Clinic staff


Specific: Random sample questionnaire survey and FGDs

Each visit/contact

Weekly

Where provided, WASH facilities are being used and maintained adequately by all members of the target population.

Community members

Community leaders


Field based NGOs

Observation

Spot checks

Each visit

Output Indicators

Hygiene communication plans and materials that use both the mass media and interpersonal communication approaches are in use.

Local administration

MoHSW

WASH NGOs

Observation

Interviews with key informants

Within 3 weeks of response

Hygiene communication training and orientation for all implementers and secondary target audiences has been carried out and reviewed.

MoHSW

MoE

WASH NGOs

Observation


By week 8 of response

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Information on the response is regularly provided to affected communities and feedback and complaints mechanisms are in place.

Community volunteers

Field workers

Observation


FGDs

By week 8-12 of response

Process Indicators

Communication materials have been developed with the target audiences and are interesting, acceptable and visible

Fieldworkers

MoHSW

WASH NGOs

FGDs

Observation

Ongoing

The majority of participants in FGDs feel that they have been provided with adequate information about the response and that field workers are working collaboratively and respectfully with them.

Field based NGOs

Independent assessor

Discussions with affected communities

FGDs

Each visit/contact

After 1 month then every 2 months

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Additional – for health care workers

Key Messages for Health Care WorkersObjectives Key Messages Communication

methods and channels

To help save lives through appropriate actions, to prevent transmission of cholera in health facilities

Patient isolation:

1. Treatment centre to work on a triage – with separation of observation, mild and severe cases

2. Access within the centre to be limited to staff and one carer per person

3. If possible separate women and men patients, even if by a screen

General and patient hygiene in CTC:

4. Disinfect and contain all faeces and vomit

5. Provide separate toilets and bathing units for patients and carers to staff

6. Strict hygiene procedures to be undertaken at all times – hand-washing with chlorinated water, footbath at entrance

7. All ground surfaces to be fully cleanable including the latrine

8. Protective clothes to be worn in the centre by staff – overalls, gloves, plastic apron, gum boots

9. Disinfect clothes and bedding of infected people before they leave the centre – either with chlorinated water or by boiling

10. Neutral area to be provided for food preparation, staff resting, storage

Use appropriate chlorine solutions:

4. 2% solution – waste and excreta, dead bodies

5. 0.2% solution - floor, objects / beds, footbaths, clothes, house spraying

6. 0.05% solution – hands, skin, surfaces of transport

7. Drinking water – use WaterGuard (liquid or tablet)

Food for patients, carers and health staff:

8. Food only to be prepared in the centre

Training of health staff

Instruction notices / posters

Guidelines

Hygiene outside the centre:

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1. If people arrive in public transport the vehicles should be disinfected

2. People’s houses should be disinfected in all areas where there have been vomit and faeces

3. Use the opportunity of helping people to disinfect their homes to also investigate if anyone else is sick and to do hygiene promotion with family members and neighbours

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Acknowledgements for the series of emergency WASH toolkits, 2010These toolkits have been developed by members of the Water, Hygiene and Sanitation (WASH) sector in Tanzania as part of a series of emergency WASH toolkits in 2010.

A wide range of people have been involved in their development, starting from a cross-Ministry and inter-disciplinary team who developed the communication framework for cholera emergencies and the cholera IEC materials in 2009. This was followed by a review of the emergency hygiene promotion activities from the previous year in mid 2010, and the development of the emergency hygiene promotion guidelines. This was undertaken with the facilitation of an international consultant from RedR, Suzanne Ferron, Husna Rajabu, MOHSW, Health Education & Promotion Unit of the MOHSW, and Justus Olielo from UNICEF. Suzanne Ferron produced the first version of the Hygiene Communication in Emergencies Guidelines and assisted the sector to strengthen the Communication Framework, developed at an earlier stage by the sectoral team.

Organisations who have participated in these processes include but are not limited to: CMO-DMD; Concern Worldwide; Help Age; MoEVT (Mainland); MOH (Zanzibar); MOHSW (Mainland – Epidemiology, EPR, Environmental Health, Health Promotion); MOW (Mainland); MOW (Zanzibar – Unguja and Pemba); PMO-DMD; PSI; TRCS; UNICEF; WHO; ZAWA; Handeni, Magu, Kasulu, Kigoma, Kilosa District Councils; and Mwanza Regional Secretariat.

Materials have also been used from the RedR supported training in 2010, for Emergency WASH for Cholera, Flooding and Displacement. The RedR facilitators for this training were Eric Fewster and Ritva Janti with the support of a range of co-facilitators from the Tanzanian sector and also from the International Federation and Red Cross Society in the East Africa regional office and the UNICEF ESARO regional office.

Following the key activities noted above, a sub-group focusing on capacity development for the Tanzanian emergency WASH sector continued on to develop the full set of toolkits. Members of this sub-group include: Burton Twisa, Concern Worldwide; Hijja Wazee, HelpAge Tanzania; Salum Abubakar, Ministry of Health, Zanzibar; Clement Chacha and Susan Nchalla, Environmental Health & Sanitation Unit, MOHSW; Mrs Husna Rajabu, Health Education & Promotion Unit, MOHSW; Dr William Kafura, Epidemiology, MOHSW; Dr Faraja Msemwa, Emergency Preparedness and Response Unit, MOHSW; Kheri Issa Ngwere, Abdallah Bunga and Adam Karia, Tanzania Red Cross Society; Rebecca Budimu, Daudi Makamba and Sarah House, UNICEF.

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