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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 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) 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? 3 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, 1 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 4 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 5 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: 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 6 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, 7 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) 8 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 2 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 9 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 10 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 11 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 12 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 13 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 14 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: 15 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 16 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. 17