Download Tanzania: Communication framework for cholera

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 Toolkits
For 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)
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What feasible priority actions or practices are
required to protect their health?
What are the key obstacles that make these
practices difficult or prevent people from taking
action? (As they see it)
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
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
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
Key questions
Summary of understanding so far
What motivates people who already practice the
desired behaviour? (Doers and non doers)
(Assessment to be carried out)
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?
 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
Older women/TBAs Radio, CORPs, Street Government,
(E.g. nurture, disgust, affiliation, convenience etc.)
What are the trusted methods of communication
used by the different target groups? (Ask who do
you go to for advice)
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?
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?
Functioning hand-washing stations next to public latrines?
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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
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.
Information provided in mosque,
church etc.
Information provided at community
meetings, markets, bus station,
bars and clubs, clinics etc.
Community based volunteers
(e.g. CORPs, Red cross
volunteers)
Shehias, religious leaders,
Imams
Community leaders and
committee members
National and local radio spots
1. Signs and symptoms of cholera
Newspapers
2. Mode of transmission
Musical events
3. Location of treatment centres
Mobile video units (note – could
use experience of people severely
affected by cholera in Pemba to
prepare a video to influence others)
4. Preventative & control measures: see below (personal
hygiene, food, water, environmental sanitation & hygiene,
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Household information and
leaflets/fact sheet
Communicators/ person
responsible
Water user associations
Name radio stations and
contacts
The messages for the primary target audience were compiled by an interagency working group in response to the cholera outbreaks in 2010
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Target Group
Key messages /concepts/actions desired
Communication methods &
locations
home based care with ORS / fluids/ funeral safeguards)
Communicators/ person
responsible
Public address system
a. Do not drink local brew during cholera outbreak
Lamgambo
b. Do not hide a patient with cholera symptoms – take
him/her immediately to the treatment centre
Mobile phones
Your health is in your hands – wash your hands with soap and
flowing water:
Clinic staff/ Environmental
health officers
District health committees
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
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
Household visits
TRCS, CHW, TBAs
Information given by outreach
workers and volunteers at women’s
group meetings
NGOs, extension workers
Information and leaflets provided at
clinic
Nurses and doctors
Only drink safe water:
1. All drinking water should be boiled or treated with chlorine
Be very careful with food:
Religious leaders
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Target Group
Key messages /concepts/actions desired
Communication methods &
locations
1. Do not eat fruits without washing: fruits should be cleaned with
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:
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After using a latrine
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After cleaning child’s bottom
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Before eating and before feeding a child
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Before preparing food
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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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Communicators/ person
responsible
Target Group
Key messages /concepts/actions desired
Communication methods &
locations
Communicators/ person
responsible
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
Include in school lessons and
assembly
Teachers
2. Yes – as a precaution we are required to always drink safe
water boiled or treated
Information: posters / flyers on
school notice boards and other
prominent places
3. Be careful with foods-don’t eat cold or open food
Drama
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
Competitions, games
Music
Environmental health staff.
TRCS staff and volunteers
NGOs working with children
Children’s councils
5. Wash hands with clean water and soap after visiting toilet or
after playing and before eating.
Peer educators
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
Shehias, religious leaders,
Imams
Information given at parent groups
Madrassas and Sunday schools
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
Secondary School
Children
1. As above
Leaflets, booklets
2. Spread the word and help protect your family and community
Peer educators
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
MOE
Fact sheets
Environmental health officers
Rapid orientation/training and
certification system?
Market inspectors
Community volunteer
3. Serve only boiled or treated water for drinking or
making juices,
4. Serve hot food,
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Target Group
Key messages /concepts/actions desired
Communication methods &
locations
Communicators/ person
responsible
Fact sheets
EHOs
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)
Water department
1. Collect water from safe sources
Rapid orientation
2. Keep the surroundings of the water source in clean and
hygienic condition, avoid haphazard spilling of water
NGOs
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
Other (i.e. identified
as a result of ongoing
assessment during
response)
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Public address
Target Group
Key messages /concepts/actions desired
Communication methods &
locations
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
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.
Communicators/ person
responsible
Teacher training and in-service
education
MoE
Briefing/orientation /leaflets at
religious conventions
MOHSW
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.
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.
Local meetings
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??
Youth
groups/women’s
groups etc.
1. You can make a difference in the cholera outbreak
MOHSW
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.
Journalists, radio and
TV producers
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1. Key facts about cholera prevention and control addressing
myths, beliefs and practices
Press conferences
These messages are examples only and have not been ratified by the interagency working group
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Ministry of Communication
and Transport
Target Group
Key messages /concepts/actions desired
Communication methods &
locations
Communicators/ person
responsible
2. Signs and symptoms
Media Briefings
MOHSW
3. Mode of transmission
Fact sheets
Media NGOs
4. Prevention and control measures (hand-washing WITH SOAP,
latrine use, food hygiene, personal hygiene etc)
Website
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
Clinic health staff
1. Importance of hand-washing with soap at key times and after
patient contact
Flip charts
MoHSW
Leaflets
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
Discussion with patients and
relatives
Reminders (cues for action) e.g.
posters at hand-washing points
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
Briefing paper
What you plan to do about it and what support you need
Proposals
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MoHSW
WHO?
WHAT is their role with regard to hygiene
communication during response?
Action required now to prepare for future
response?
Who will lead/coordinate hygiene
communication
efforts? (E.g. lead
agency, committee,
working group etc.)
RMO/RHO
Mobilization of resources
Review policies and guidelines
DMO/DHO
Co-ordination
Supervise implementation of HIMS
What human
resources are
available to
communicate
hygiene?
RHMT members
ZMO
Oversee emergency preparedness plans
(including hygiene communication plan)
Capacity assessment
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
Training on emergency response and update on
hygiene communication
Community education and mobilisation
What other ministries
should be involved?
What other partners
should be involved?
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
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
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
General: Observation, discussion, questioning
Each visit/contact
Community Volunteers
Specific: Random sample questionnaire
survey and FGDs
Weekly
Community leaders
General: Observation, discussion, questioning
Each visit/contact
Community Volunteers
Specific: Random sample questionnaire
survey
Weekly
Community leaders
General: Observation, discussion, questioning
Each visit/contact
Community Volunteers
Specific: Random sample questionnaire
survey and FGDs
Weekly
Community members
Observation
Each visit
Community leaders
Spot checks
Field based NGOs
Clinic staff
A 25% increase in households correctly using WaterGuard
to treat drinking water (where promoted)
Field based NGOs
Clinic staff
A 40% increase in households who can list 3 key ways to
prevent the spread of cholera (if your objective is to provide
information)
Field based NGOs
Clinic staff
Where provided, WASH facilities are being used and
maintained adequately by all members of the target
population.
Community Volunteers
Field based NGOs
Output Indicators
Hygiene communication plans and materials that use both
the mass media and interpersonal communication
approaches are in use.
Local administration
Observation
MoHSW
Interviews with key informants
Within 3 weeks of
response
WASH NGOs
Hygiene communication training and orientation for all
implementers and secondary target audiences has been
carried out and reviewed.
MoHSW
Observation
MoE
Interviews with key informants
WASH NGOs
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By week 8 of response
Information on the response is regularly provided to
affected communities and feedback and complaints
mechanisms are in place.
Community volunteers
Observation
Field workers
Interviews with key informants
By week 8-12 of response
FGDs
Process Indicators
Communication materials have been developed with the
target audiences and are interesting, acceptable and
visible
Fieldworkers
FGDs
MoHSW
Observation
Ongoing
WASH NGOs
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
Discussions with affected communities
Each visit/contact
Independent assessor
FGDs
After 1 month then every 2
months
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Additional – for health care workers
Key Messages for Health Care Workers
Objectives
Key Messages
Communication
methods and channels
To help save lives through
appropriate actions, to
prevent transmission of
cholera in health facilities
Patient isolation:
Training of health staff
1. Treatment centre to work on a triage – with separation of observation, mild and severe cases
Instruction notices /
posters
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
Hygiene outside the centre:
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Guidelines
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, 2010
These 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 crossMinistry 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: CMODMD; 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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