Communication Strategy on Water, Sanitation & Hygiene for ...
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1 Communication Strategy on Water, Sanitation & Hygiene for Diarrhoea & Cholera Prevention Liberia, 2012
Transcript of Communication Strategy on Water, Sanitation & Hygiene for ...
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Communication Strategy on Water, Sanitation & Hygiene for Diarrhoea & Cholera Prevention
Liberia, 2012
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Photos & Design: ©UNICEF/Liberia/ Rudrajit Das United Nations Children’s Fund (UNICEF) Liberia October, 2012 United Nations Children’s Fund (UNICEF) Liberia Bright’s Apartment, Sekou Toure Avenue Mamba Point, Monrovia, Liberia Tel: +44 207084 9761 Fax: +44 207 084 9760 [email protected] www.unicef.org
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Communication Strategy on Water, Sanitation & Hygiene
For Diarrhoea & Cholera Prevention
Liberia, 2012
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Acknowledgements
This communication strategy aims to contribute towards promoting behavioural change among families and communities in Liberia around Water, Sanitation and Hygiene with a focus on the prevention of Acute Watery Diarrhoea and Cholera. It intends to provide a framework for designing and implementing communication interventions on the issue across the country. Thanks are due to Reverend Sumo - Director, Health Promotion and his team at the Ministry of Health and Social Welfare, Republic of Liberia for their support, cooperation and insights. The inputs of several partners such as Water Aid, PSI, CODES, FAAL, Oxfam, LICH and Concern is duly acknowledged. The support, inputs and contribution of UNICEF Liberia colleagues is deeply appreciated – Isabel Crowley, Laura O’Hara, Sam Treglown, Julia Moore, Miraj Pradhan, Kinley Dorjee, Adolphus Scott, Stephanie Clayton, Faizah Samat and Manish Philip. Thanks are also due to Natalie Fol, Maria Bardolet and Fabio Friscia from UNICEF WCARO for their guidance, support and suggestions. This strategy was authored by Rudrajit Das from the Communication for Development section of the UNICEF India Country Office.
October 2012, Liberia
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Table of Contents
CHAPTER 1
Introduction
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Background
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Focus Areas
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CHAPTER 2
Communication Goal and Objectives
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Participant Groups
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CHAPTER 3
Promoting Water, Sanitation and Hygiene
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Communication Approaches
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Key Segments and Interventions
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Treatment
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CHAPTER 4
Preventing and Managing Outbreaks of AWD/Cholera
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Preparedness Phase
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Response Phase
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CHAPTER 5
Implementation
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Monitoring and Evaluation
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CHAPTER 6: Annexures
Annexure 1: Behavioral Analysis
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Annexure 2: Field Visits, Discussions &Observations
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Annexure3: Promoting WASH- Key Segments & Interventions
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Annexure 4: Preparedness & Response for Cholera – Phases
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Annexure 5: Communication Matrix: Current Views, Themes to Address, Communication Methods and Inputs
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Annexure6:Template for National and County Implementation Plans
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Annexure 7: Indicators and M&E Framework
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Annexure 8: UNICEF’s Core Commitments for Children in the areas of Water, Sanitation and Hygiene and corresponding BCC and social mobilization support
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Annexure 9: Useful communication channels in an emergency
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Annexure 10: How to Design a Radio Spot
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Annexure 11: How to Design Print Materials
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Annexure 12: Key Messages
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Annexure 13: Suggested Materials
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Annexure 14: Cholera – Some Basic Facts
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Annexure 15: Key References
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Tell Me
Why?
CHAPTER 1
Introduction, Background
& Focus Areas
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Introduction
ince the end of the civil war in Liberia in 2003, there have been marked gains in infant and child survival, spread of basic health care services, expansion of primary education, water and sanitation improvements, better social welfare and child protection including child justice.
Peace-building and human developments have also moved ahead in tandem. But fragile livelihoods, youth unemployment, female vulnerability and food insecurity remain critical problems. There is also very uneven access to basic services with much lower access in rural as compared to urban areas, and in the Southeast and Northwest counties compared to other counties1. The Poverty Reduction Strategy (PRS) 1 estimated that 64% of Liberians lived below the absolute poverty line and 48% were extremely poor. The population of the country stands at 3.5 million. The ‘big six’ administrative counties – Montserrado, Nimba, Bong, Lofa, Grand Bassa and Margibi contain 76% of the population. Of these, three – Montserrado, Nimba and Bong hold 55%. At the other end of the scale, the ‘small five’ – Grand Kru, Rivercess, River Gee, Bomi and Gbarpolu contain 10.5%, a drop from 12% in 1984, indicating a tendency for people to gravitate towards more populated areas, especially Montserrado where the population density is high by sub-Saharan standards at 1500 per square mile2. This includes the capital Monrovia, which has 1.1 million people, nearly a third of the country’s population3. Here children are raised in crowded shacks without sanitation and with the risk of water-borne diseases such as cholera. Another population facing high risks is the refugee population along the border with Côte d’Ivoire. Here, as in any crowded environment, special risks may arise simply from the large numbers and densely packed nature of camp settlement. Liberia is a well-watered country, with plentiful rainfall and abundant rivers and streams. But the development of engineered water supply infrastructure is minimal. Lack of household water and sanitation services, which oblige people to spend hours a day collecting water, and to dispose of their excreta in the open and by methods that are personally undignified, are part of being poor and service deprived4. Further, there is limited knowledge and low levels of practice in relation to safe water, sanitation and hygiene. Hygiene-related diseases, including worm infections contribute to about half of the overall malnutrition and are a major contributor to child morbidity and mortality. Cholera occurs in Monrovia and is a risk in crowded environments including refugee camps. Given the poor condition of water, sanitation and hygiene; overcrowding in urban areas; history of Cholera in the country and sharing of a relatively porous border with Cholera endemic countries such as Sierra Leone, Guinea and Côte d’Ivoire, the country is at risk for Cholera outbreaks. In order to address this, along with improving water and sanitation services, there is an urgent need to carry out communication interventions in order to promote the demand for water and sanitation services as well as address critical hygiene behaviors. The Water Sanitation and Hygiene Sector Strategic Plan identifies that ‘Scaling up hygiene promotion efforts is an important pre-requisite to achieve the PRS 2 sanitation target’. Further, it emphasizes that ‘A communication and advocacy framework for hygiene promotion needs to be developed and a variety of Information, Education and Communication approaches will be needed to reach different target groups to meet the scale-up objective’. In this context, the Health Promotion Division of the Ministry of Health and Social Welfare in collaboration with UNICEF has developed this
1 Situation of Children and Women in Liberia 2012, Government of Liberia and UNICEF
2 LISGIS 2008 Population and Housing Census Final Results, May 2009. 3 IMF mid-2010 forecasts, quoted in Liberia, the Economic Intelligence Unit, London, May 2011, p 4. 4 Water, Sanitation & Hygiene Sector Strategic Plan for Liberia, 2011-2017, p 19, citing First Revised/Edited Draft Liberia PPA Preliminary Analysis, March 5, 2008.
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communication strategy on Water, Sanitation and Hygiene with a focus on Diarrhoea and Cholera prevention to guide initiatives around the same in Liberia. The first part focusses on promoting water, sanitation and hygiene and the second on managing communication for cholera preparedness and response. The main body of the document is a synopsis of the strategy with links to annexures in relevant sections for more detailed information.
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Background
ccess rate to an improved drinking water source is 68% nationwide, 79% in urban areas and 51% in rural areas5. Very few households – only 1%– have piped water connections; most protected sources are hand-dug covered wells in shallow water table areas or bore-holes with
hand pumps in hard-rock or low water-table areas. However, among those with such access, a recent mapping exercise revealed that a significant proportion (40%) has either broken down, or do not yield sufficient water year round6. At present, there is not yet a sense of community ownership of protected water-points, nor an effective system for their maintenance and repair. Results of the 2007 Liberian Demographic and Health Survey (DHS) that showed substantial problems with diarrhoea in children less than 5 years old and concern about recurring cholera outbreaks have generated significant interest in establishing a household water treatment strategy for Liberia. The DHS showed that 16% of households reported treating their drinking water with bleach or chlorine and 80% of household reported doing nothing to treat their drinking water7. In addition, it is common practice to use locally available calcium hypochlorite powder to “shock chlorinate” wells and hand pumps, a practice which has been shown to be ineffective for keeping water safe for more than 24 hours post-treatment8. Furthermore, in Liberia there is no standard shock chlorination practice. Calcium hypochlorite concentrations, doses, and treatment frequency are not standardized, and monitoring of residuals typically does not occur9. The disposal of human waste presents an even greater challenge. Nearly half the population of Liberia defecates in the open (with relatively few having a decent household toilet). Only 17% of the population has access to improved family sanitation facilities while 20% use shared facilities. The situation is more alarming in rural areas where only 4% have access to improved sanitation facilities while 77% practice open defecation10. In rural areas, villages are often closely settled, with alleyways leading between densely packed housing; so unless people go some way off into the bush, open defecation represents a serious public health hazard. In urban areas, where housing is much more dense, open defecation practiced by 30% of urban dwellers into water courses, in ditches, on beaches, and in plastic bags thrown onto rubbish dumps presents even worse risks of diarrhoeal epidemic. Only 25% of households in urban areas have access to improved sanitation facilities. These bad sanitation conditions are exacerbated by the high water table in many urban slums in Monrovia. Lack of solid waste disposal, poor drainage and rotting garbage leads to plagues of vermin and a bacteria-laden environment. However, there is strong demand for sanitation in poor urban areas. There is also approval for a clean and hygienic environment in rural ‘towns’, and a good response to the Community-Led Total Sanitation (CLTS) approach that encourages communities to build household toilets and become ‘open defecation free’ (ODF). Annual admissions to the Cholera Treatment Unit in Monrovia averaged 2,600 between 1996 and 200811. Although the number of annual suspected cholera cases declined to stand at 1,379 in 2009, all (100%) of cases in Liberia were Monrovia residents. The annual hospital admissions due to cholera remained stagnant between 2008 and 2009 with 484 and 480 cases respectively. Although there have been a few cases of cholera in 2012, the number of cases of Acute Watery Diarrhoea
5 WHO/UNICEF Joint Monitoring Programme, 2010
6 Water Point Mapping, UNICEF 2011
7 Liberian Demographic Health Survey, 2007 8 S. Luby, Md.S. Islam, R. Johnston. Chlorine spot treatment of flooded tube wells, an efficacy trial. Journal of Applied Microbiology 2006;
100: 1154-1158. 9 KAP baseline on Water treatment, Hygiene Diarrheal Diseases and ORS/ORT in Liberia, Liz Blanton 2008
10 WHO/UNICEF Joint Monitoring Programme, 2010
11 UNICEF Report: Assessing WASH Package in five counties of Liberia, 2010, op cit, p 7
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(AWD) by the end of the 34th week, stood at 3492. The major contributors to this by county were: River Gee - 495, Grand Cape Mount - 427, Maryland - 466, Montserrado -386 & Grand Gedeh - 31812. A KAP baseline13 on Water treatment, Hygiene Diarrhoeal Diseases and ORS/ORT was carried out across the counties of Montserrado, Grand Bassa and Grand Gedeh in Liberia. The study revealed that the two most common water sources for all three urban areas were protected wells with pumps and public taps or standpipes. The most common water sources in the rural areas were river or steam and unprotected spring. Over half the urban households (51%) and 26% of rural households transported their water in 5 Gallon (20-L plastic jerry cans) and 68% and 61% of urban and rural households respectively stored their water in these containers. The median amount of time to obtain water from the source was 5 minutes for both urban and rural households with a range of 0-60 minutes for urban households and 0-35 minutes for rural households. 22% of urban households and 24% of rural households reported ever having treated their drinking water by any method. Of these the three most common water treatment methods in urban households were adding chlorine powder (82%), adding chlorine liquid (39%) and/or adding purifying solution (23%). There were no predominant treatment patterns identified in rural households. Use of all other treatment methods such as using iodine, tablets, boiling, sand filtering and settling was reported by few respondents. Free chlorine residual was detected in a total of 3% of total household water samples tested. Among the 263 households who reported treating, 20 (8%) samples were positive. These 20 households represented less than 2% of the total study population. In terms of sanitation and hygiene practices, out of the households surveyed, 59% urban households and 28% of rural households used either a pit latrine or flush toilet. Flush toilets were most prominent in Monrovia. 29% percent of urban households and 64% of rural households practiced open defecation in the beach, river or bush. Rural households were less likely to have access to an improved method of sanitation. 51% of urban households and 22% of rural households shared their toilet facility with another household. Less than half of the households disposed of their child’s stool in a latrine. Reported hand washing practices among the among urban and rural households were high with over 80% of households reporting both washing their hands before feeding the child and after cleaning up after the child following defecation. This did not differ greatly between counties or within urban or rural populations. Most households (71%) reported washing their hands most often with water and soap and 90% of households were observed to have soap in the household. 43% of households reported always or frequently washing their hands with soap before preparing food and 63% of households reported always or frequently washing their hands with soap after using the toilet. 44% urban households and 60% rural households reported a child under five having diarrhea in the last month. The most common treatments of diarrheal diseases were ORS/ORT, 66%, antibiotics 45%, and anti-diarrheal medication, 42%. The use of ORS to treat a child’s diarrhea did not differ significantly between counties but urban caregivers were more likely to give it to their child than rural caregivers. Caregivers strongly believed in the safety, effectiveness, and need to treat their child’s diarrhea with ORS.
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MOH&SW Weekly Epidemiological Bulletin 13
KAP baseline on Water treatment, Hygiene Diarrheal Diseases and ORS/ORT in Liberia, Liz Blanton 2008
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Focus Areas
his section builds on a Behavioural Analysis developed through a review of secondary literature, discussion with government counterparts, NGO partners, UNICEF staff, field visits and observations. It provides the key areas that need to be focussed on and related
recommendations to be considered while rolling out the strategy through detailed implementation plans. The detailed Behavioural analysis has been provided in Annexure 1
1. The use of sanitary facilities, safe water and hygienic practices are very low. In addition to access, there are issues related to knowledge and behavior. The link between unsafe practices and diseases such as diarrhea and cholera is often not clear. Hence this will have to be focused on. A distinction should be made between people not knowing, knowing and not believing, and knowing and not practicing due to cost or logistics. Interventions should therefore acknowledge the different strategies that each of these will need to encourage change, and incorporate these.
2. It is important to first understanding the motivations and barriers to change and
participation before starting. It should be acknowledged that the hygiene/sanitation information that communities learn may be thought of as a new belief system, because in reality, they cannot see germs, and there is not a perfect cause and effect relationship between good hygiene and good health. This “new” belief system, unfortunately, might be in competition with their own beliefs.
3. There is a need to build on current positive behaviors ( like hand washing ) and incorporate
more hygienic practices, such as use of soap, more frequent hand-washing, etc. over time. However, regarding the uptake of modern hygiene practices people might be engaging in both modern and traditional practices at the same time. Many people are using soap for washing clothes, pots/dishes and for bathing. However, while many persons are washing their hands at critical times, e.g., after the latrine and before eating, many do not do so with soap, therefore, it becomes important to continue showing, how good hygiene can have an impact on disease.
4. Hierarchy in local systems affects participation. Therefore it is important to focus on
improving information dissemination systems that ensures that all community members are informed about interventions, and to help strengthen mechanisms that ensure selection criteria for community contact persons/ leaders are effectively adhered to. This could ultimately lead to a fairer selection concerning who participates in interventions. Mini assessments that include multiple sources of information need to be carried out in partnership with communities prior to project implementation to assess who may actually participate in interventions, community meetings to ascertain actual needs, discussions with field staff to establish needs and who may be appropriate leaders, etc.
5. Change in behaviors takes time and requires sustained efforts. Communities need to be
engaged with frequently. Once dialogue has been initiated in each community, periodic visits to households should be undertaken to encourage continuing practice of hygiene behaviors. It may also be possible for other activities to be encouraged, such as special days to clean their yards, for washing hands, etc. Thus the communication plan would need to include repeated visits and opportunities for engagement with families and communities.
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6. Flexibility will have to be at the core of community interventions. There might be seasons when people are not available during the day because of field work or other preoccupations. Perhaps then, communication activities might need to be carried out in the evenings. Each community has very different needs. Interventions need to be tailored accordingly. Further, there should be a realistic assessment of what works and what does not, and willingness to engage in alternative interventions by communities.
7. Other priorities such as livelihood require the bulk of people’s time and attention. Hygiene is something additional to be done if there is sufficient time and energy after their priorities have been addressed. At this point, modern hygiene practices are not very important because people do not truly understand its importance to their daily lives. Adults and children are born, grow and die – most will survive and become strong. Therefore, some of the lessons of hygiene/sanitation interventions may not seem crucial for survival. Further they might feel there is no reason to follow newer practices as for example, their ancestors did not do these things. Therefore there is not a compelling reason to do more than they are currently doing. This lack of importance and the influence of culture would need to be addressed.
8. Men are more likely to have knowledge on safe water, sanitation and hygiene as compared
to women but women are the ones who play a more critical role when it comes to these issues at the household level. Further, they are the ones affected the most by the lack of water and sanitary facilities. Hence there is a great need to make special efforts to include women in all communication activities. Emphasis should be given on trying to provide them with leadership roles. Women are usually more easily organized, appear more likely to work on projects, and are more intimately aware of the survival needs of the family.
9. In many instances it may be important to have separate community meetings according to
gender as women many not be comfortable speaking in the presence of men, especially if they are from their own family or neighborhood. Age may also be looked into as younger women are often less willing to speak in the presence of older women.
10. In some places, there are certain geographical areas that appear to be regularly left out of
information sharing because they are further away from the center of the village, are in outlying areas, or are sparsely populated. Special efforts need to be made to ensure that socially and geographically excluded pockets are included
11. Services related to Water, Sanitation and Hygiene would need to be stepped up in tandem with communication activities otherwise it would defeat the purpose of engaging in communication activities with communities. Many of the challenges for uptake of new hygiene and nutrition practices relate to cost and logistical barriers. Buying buckets with covers and using soap to wash hands after toileting, all take time or money. People would use pump water or latrines if available, but revert to traditional practices when not available. Similarly, although people might go to health centers, if medicines did not work, they would resort to traditional medicine.
12. Possibly due to the effects of war and being supported by various NGOs for many years, there is an element of dependency among many in the communities. The issue of dependence, or the assumption that the implementers of interventions will come in to fix equipment and / or supply their needs, would have to be addressed thorough ensuring community and individual ownership in interventions.
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13. There is a need to for all stake holding ministries/ departments such as Health, Public Works, Education, Land Mines and Energy, Internal Affairs, Information, Culture and Tourism, Nutrition and NGOs/development partners to work collectively and support each other. Advocacy and setting up of coordination mechanisms at all levels would be critical for ensuring this.
14. A direct challenge of the influence of supernatural factors may be ineffective; however, there are some areas, for example, causes of common illnesses, where communities appear to be open to new education. This openness could be utilized in educational interventions to address issues related to the supernatural.
This communication strategy has been developed based on secondary literature, discussions with government ministries, NGO partners and field visits. It is highly recommended that in order to validate key knowledge, attitudes, perceptions, barriers and practices related to water, sanitation and hygiene, a formative study be carried out. This would need to be supported by a baseline before the strategy is rolled out. Further, a midline and end of term assessment would also have to be carried out to establish effectiveness.
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What needs to be done & by whom?
CHAPTER 2
Goal, Objectives
& Participant Groups
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Communication Goal and Objectives
Communication Goal: ‘The overall goal of the communication strategy is to increase the adoption of safe water, sanitary practices and hygiene among families and communities in Liberia contributing to the reduction of Acute Watery Diarrhea (AWD) and Cholera’.
Long Term Communication Objectives:
1. Increase in the percentage of families and communities that practice safer water, sanitation and hygiene behaviors by end 2015
2. Increase in the collaboration between various stake holding government ministries/ departments, development partners, media and civil society organizations at all levels to advocate for as well as address issues related to water, sanitation and hygiene by end 2015
3. Increase in the number communities actively participating in the management of water, sanitation and hygiene in their areas by end 2015
4. Increase in the percentage of families and communities who practice recommended water, sanitation, hygiene and treatment seeking practices during AWD and Cholera outbreaks by end 2015.
While communication would be contributing towards the achievement of the above mentioned objectives, they would also depend to a great extent on the availability of necessary water, sanitation and hygiene services as well as levels of engagement of different stakeholders. Hence it would also be important to track some short term objectives, the attainment of which could be directly attributed to communication efforts.
Short Term Objectives
1. Increase in the percentage of families who are knowledgeable about the importance of safe water, sanitation and hygienic practices and the risks of not following them by end 2013
2. Increase in the percentage of families who strongly believe that it is important to follow safe water, sanitation and hygiene practices by end 2014
3. Increase in the participation of various stake holding government ministries/ departments, development partners, media and civil society organizations at all levels on issues related to water, sanitation and hygiene (including AWD and Cholera )by end 2013
4. Increase in the number of families and communities with the required skills and motivation to manage outbreaks of AWD and Cholera by end 2014
All short term and long term objectives would need to be quantified and targets set, once a KAP baseline is carried out
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Primary Participants: Those among whom the actual intended change is envisaged
Secondary Participants: Those who Influence the behavior of primary participants
Tertiary Participants: Those with whom advocacy to create a favorable structural and social environment would be carried out
• Children
• Men / Women/ Parents
• Food / Water Vendors
• Teachers
• GCHVs, TTMs, HHPs, EHTs, PAs, Nurses, Doctors
• Community leaders, Religious Leaders
• Parmount chiefs/ Clan chiefs
• Women's groups
• Trader's associations
• Video club / parlour/ salon owners/ barbers
• Community toilet operators
•County / District Level- Superintendent / Comissioner, Health Officer, Community Health Director, HP focal point
• National Level- Senators/ Legislators, Ministers, Directors from Health, MPW, MIA, Education, Information, Nutrition & LME
• Media, CR Association , Football stars
Participant Groups
very communication strategy aims to work with key, predetermined participant groups. In order for the strategy to be effective, it has to be relevant to the needs of each of the participant groups. Therefore it is important to analyse the needs and characteristics of each
of the participant groups in order to be able to tailor the strategy to their needs and help them practice as well as maintain the recommended / desired behaviors. Different communication approaches, messages and content for dialogue will be needed for each of the participant groups. Participant groups and their relationship have been depicted in the figure below:
Participant groups and their Relationship
The strategy mainly aims to reach out to and ensure behavioural change among Primary Participant groups i.e. Children, their Parents and Food and Water vendors. But there are other Secondary Participant groups such as Teachers, Community leaders/religious leaders, GCHVs etc. who directly influence the behaviour of Primary Participant groups and need to be engaged with as well. For e.g. if GCHVs decide to motivate parents to adopt latrines and safer water practices and community leaders facilitate the access of families to latrines and safe water, parents would be motivated/ have the ability to adopt positive practices. The change in social norms by religious leaders/ influencers around sanitation and water would also help parents to change/ maintain their behaviors. Further, a great deal of advocacy would also need to be carried out with the Tertiary Participant groups such as policy makers / implementers and the media as they directly or indirectly influence the intention/ability to act of the secondary participant groups as well as primary participant groups. For instance if the policy makers /implementers improve the implementation of water and sanitation facilities and the media / community radio association vigorously highlights the issue and associated harms of not adopting recommended practices, families and communities would be motivated to follow proper sanitation and hygiene practices. Participant groups, their current views, themes to address them, communication methods and inputs have been provided in Annexure 5.
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We help promote WASH!
CHAPTER 3
Promoting Water,
Sanitation & Hygiene
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Promoting Water, Sanitation and Hygiene
Introduction
s stated in the communication objectives, the strategy intends to facilitate behavioural change not only among individuals but also among communities. This is critical from the point of view of sustaining change as individuals seldom operate in a vacuum. Sustained change
requires a supportive, enabling environment in which people are provided the motivation and encouragement that they need. In this respect, favourable social norms become a crucial element in ensuring change. This however, needs to also be supported by the efficient delivery of essential services. Thus, there is a need to focus on the individual’s environment at various levels from the household and community to the institutions responsible for providing services and the overall policy framework. The Socio-Ecological model provides a framework to understand this. According to the model: ‘Individual behaviour both influences and is influenced by multiple levels of influence’. Thus addressing each of these levels is required in order to bring about change. These levels have been depicted in the model below.
Socio – Ecological Model
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Communication Approaches Evidence shows that the most effective means of promoting change is to work at the levels depicted above and using multiple channels of communication that are suited to the individual levels. The main communication approaches suggested for the different levels and achieving the communication objectives are advocacy, interpersonal communication, community mobilization, supported and reinforced by mass media.
Advocacy: Aims to engage the support of influential organizations and individuals and target
people in positions of power. Advocacy would help influence policy and to raise the issue of water, sanitation and hygiene higher in the policy agenda and in the minds of the people.
Interpersonal communication: would be one of the key approaches of this strategy in order
to increase knowledge on the importance of water, sanitation and hygiene as well as promote behavioral change among families and communities.
Community mobilisation: would be carried out to strengthen dialogue among community
members on issues of water, sanitation and hygiene. It would provide the platform to help increase community participation and ownership.
Mass media, outdoor media and folk media: would be useful to raise mass awareness,
bring the issue into the limelight and also help promote critical behaviors and programme information. Simultaneously, they would also provide support and credibility to the interpersonal and community mobilization efforts.
Entertainment education: would help disseminate messages through means which are
educational in substance, entertaining in structure and popular in the community. For instance, a radio drama on water sanitation and hygiene made in a format that is locally popular.
Social marketing: Considers marketing principles such as ‘product, price, positioning and
promotion’ (4Ps) to encourage the use of a product or practice that has a social value e.g. hand washing with soap and use of water treatment products. It would help both promote adoption of behaviors and create a demand for services and supplies that help practice that behavior.
Capacity Building: In order to be able to carry out communication activities effectively, a
significant amount of capacity building activities would need to be carried out at various levels. More
importantly, for communicators in direct contact with families and communities.
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Synopsis of Key Segments and Interventions Based on the communication objectives, the strategy would have three segments.
1. Communication for promoting social and behavioural change among families and communities
2. Communication for creating a positive programme and policy environment 3. Communication for ensuring community participation and ownership
It is not essential that these segments are carried out in a sequential manner. There would be substantial overlap in the implementation of these segments. Each of these segments would have some key interventions which have been mentioned below. A detailed description of these segments and interventions is available in Annexure 3
Segment 1: Communication for promoting social and behavioural change among families and communities This segment would focus on using various means of communication to reach families and communities both directly through interpersonal / social contact and indirectly through mass and mid-media in order to help change knowledge, attitudes, beliefs, mind sets, perceptions and practices. Some of the key interventions in this segment would be: 1. Radio / Television Spots: Radio and Television spots on WASH with a positive, motivational feel aiming to address both knowledge gaps as well enhance self-efficacy among listeners would be developed and aired. 2. Radio Soap based on Entertainment-Education (E-E): A weekly, 52 episode, interactive, informative, inspirational, engaging and entertaining E-E radio soap would be developed and aired. Community linkages through ‘Listeners groups’ would also be facilitated. 3. Working with Cellular service providers: Push SMSs/Voice SMSs with key messages, co-branded TV/Radio spots and outdoor activities in partnership with cellular companies could be explored 4. Outdoor Media (Hoardings/Wall paintings) and IEC materials: These will support interpersonal communication and give credibility to community level communicators as well create an enabling environment. 5. Video Clubs: Films promoting key behaviours would be screened following by a discussion around it, demonstration of key skills and communication material distribution. 6. Community Drama: Entertaining, engaging dramas followed by a facilitated discussion, would help promote deeper understanding and positive attitudes among audiences. 7. Town Criers: Would be used to provide key information / messages to the community.
8. Beauty Parlours/ Salons and Barbers: would be oriented and motivated to talk to their customers around WASH, put up communication materials in their shops and also hand out some literature.
9. Gospel Musicians / Popular singers: They would be partnered with to include themes on water, sanitation and hygiene in their songs.
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10. Communication through GCHVs, HHPs, TTM and Animators: They would be trained on IPC skills and provided toolkits help them counsel, motivate and follow-up with families and communities. 11. Communication through Nurse, Physician Attendants, Environmental Health Technicians and Doctors: Advice and materials would be provided to them to talk to clients around WASH issues. 12. Communication through Teachers: Teachers would be oriented and motivated to promote good WASH habits among children. 13. Working with Children: A range of activities would be carried out with children such as formation of ‘Peer Counsellors’, ‘Buddy Pairs’, School Health Clubs and special classroom/community activities to promote and inculcate positive WASH behaviours among them. 14. Working with Community Influencers and Religious leaders: They would be oriented to motivate and mobilise their communities around WASH. 15. Working with Food and Water Vendors: Since they form a critical link in the transmission of diarrhoea/ cholera they would be oriented to maintain proper sanitation and hygiene. 16. Showcasing Cases of Positive Deviance at the Community Level: Families practicing recommended behaviours would be identified and given due recognition to motivate such families as well as other families to follow their example.
Segment 2: Communication for creating a positive programme and policy environment Advocacy will play a key role in ensuring that there is a positive environment in which the WASH programme can be implemented effectively. The thrust of Advocacy will be to establish the context and relevance of the cause. An effective advocacy campaign can also get support from media and can keep the issue alive for a longer period of time in the public domain. Some of the key interventions in this segment would be: 1. Advocacy through media: The media would be an important ally for advocacy. Workshops, media visits, fellowships, awards and special programmes through them would help promote and push the WASH agenda. 2. Advocacy through Celebrities: Celebrities would help highlight the issue at various forums and give visibility and relevance to the cause. They could also help influence policy matters. 3. Advocacy with policy makers: such as Senators and Legislators would be carried out through workshops and meetings to ensure that WASH is given importance and both policy and programme issues are addressed. 4. Advocacy with County / District Administration and relevant authorities responsible for water, sanitation and hygiene: through meetings and workshops would help address implementation bottlenecks and also help give priority to WASH activities. 5. Advocacy with Partners for Coalition building: Partners such as INGOs NGOs, community networks, religious organizations (like the all faith association), and occupational groups etc. would be brought into the fold in order to help in the process of social mobilization through their networks
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6. Sensitization / Training of County / District Level staff: on roles and responsibilities in relation to WASH promotion would be done to ensure smooth rollout of the programme. 7. Advocacy with Municipal authorities /market owners associations / vendor associations: would be carried out so that they give priority to maintaining hygienic conditions at market places. 8. Setting up / Strengthening Coordination Mechanisms for Health Promotion at National / County and District Levels: for coordination, planning and monitoring of WASH communication activities would be done to ensure implementation with the required quality.
Segment 3: Communication for ensuring community participation and ownership Communities need to be involved and engaged in identifying their problems as well as solutions for them. Rarely do solutions given from outside sustain as there is no ownership towards them. Thus it would be critical to engage with communities and ensure their participation in WASH programmes. Given the intensive nature of engagement required for this, it would be carried out only in priority and high focus areas. Some of the key interventions in this segment would be: 1. Rapport Building with the Community: Each community has diverse needs, structures and power relations. Care must be taken to understand these, build trust and rapport before initiating work. 2. Participatory Community Needs Assessment: Communities need to be involved and engaged in identifying their problems as well as solutions for them. This is important as communities understand their issues best and only solutions identified by the community ultimately sustain as they are need-based and owned by the community. 3. Development of a Community Work Plan: Next, a community work plan with clearly identified tasks, timelines, responsibility, external support required and risks, supported by an M&E system would have to be developed. The external support component would have to be kept as low as practicable. 4. Capacity building: Before people can start acting on the work plan, they might have some capacity building needs. These would have to be identified by the facilitators and addressed 5. Formation of a Community Level Committee on Water, Sanitation and Hygiene: In order to oversee and manage the implementation of the plan, a committee comprising of community leaders and representatives from all sections of the community would have to be formed. 6. Ensuring Community Participation in the rollout: The committee would have to ensure that people contribute to the rollout of the plan through financial/ material /human resources, however small it may be. 7. Creating new social norms: The committee would also need to implement certain checks and balances to ensure that people do not revert back to their old behaviour and are engaged in the programme 8. Engaging Women: Women are often the biggest sufferers when it comes to issues of WASH. Also, they are the ones who are involved in ensuring availability of water and maintaining hygiene in families. Further projects that focus on involving women have greater chances of success. Thus women would need to be involved and provided significant roles.
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Treatment
iberia as a nation is very fond of football. People look up to football stars and idolise them. A campaign, as part of the larger communication strategy using football stars could provide great visibility to the issue, as well as help motivate people to adopt sanitary and hygienic practices.
The Liberian football team, ‘Lone Star’ could be approached to partner with for this cause. Football symbolizes competing and winning and this symbolism is a good match with the objectives of the WASH programme, which is ultimately to help people ‘win’ over diseases such as diarrhoea and cholera. This linkage could be used to design and develop a campaign. The possibilities through this proposed partnership with the Liberian football team are quite immense. Some suggested activities could include: 1. A large public ceremony to appoint the ‘Lone Star’ team as brand ambassadors for the WASH
programme by the President with extensive coverage by the media 2. A public message /appeal / oath on WASH issues by the team before every match that they play 3. Publicity through the media/ messaging around WASH whenever the team plays a big match 4. Visit by the team to select high –risk communities to talk around WASH issues with extensive
media coverage 5. Recorded voice messages /SMSs on WASH by the team sent to mobile phone subscribers 6. Development of branded communication kits with WASH messages that could be used during
community football matches 7. Radio / TV spots featuring key players 8. Hoardings, Wall paintings, Posters 9. Branded collaterals such as T-shirts, caps, flags etc. 10. Activities / games for children around WASH based on the theme of football The overall theme could be around ‘SCORING A GOAL’ or ‘WINNING’ against diseases. Draft samples of the proposed treatment are provided below: (features the captain of the Liberian football team- George Gebro)
Sample- Not for open use
L
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Sample- Not for open use
Sample- Not for open use
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We know how to prevent Cholera!
CHAPTER 4
Preventing & Managing
Outbreaks of AWD/Cholera
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Synopsis on Preventing and Managing Outbreaks of AWD/Cholera
holera is one form of acute, watery diarrhea, a symptom that can be caused by any number of bacteria, viruses, and parasites. Cholera is caused by a bacterium, Vibrio cholerae. It is one of the most rapidly lethal infectious diseases known – it is characterized by an explosive
outpouring of fluid and electrolytes within hours of infection that, if not treated appropriately, can lead to death within hours. Because of this it has become a disease that evokes fear and can lead populations to panic. However, with prompt and appropriate treatment, mortality can be kept extremely low. Furthermore, through a combination of interventions in the water, sanitation, hygiene, and health sectors, cholera outbreaks can be prevented. Successfully controlling an outbreak of cholera requires the collaboration of different stakeholders and the implementation of a variety of different interventions. Effective communication in varying forms (advocacy, hygiene promotion, behaviour change communication, communication with patients, etc.) is at the heart of cholera preparedness and response. Effective communication is critical at all levels. Examples include:
Inter-sectoral communication between ministries/departments and partners through co-ordination structures
Advocacy with policy makers and implementers to ensure a positive programme environment for prevention and response
Communication with primary audiences on prevention, preparedness and response
Communication between community workers, health care providers, patients and general population
There is often an overlap between different forms of communication strategies for preparedness and response, but it is important to remember that effective communication is complex and involves a variety of participant groups and the use of different communication strategies and channels. Communication is not just about providing information or messages to the affected community on what to do and what not to do but also needs to include mobilising government/ partners or community action. Communication interventions around Cholera would need to be divided into two distinct phases i.e. preparedness and response. It would be important to have the preparedness phase as efforts put into the same would determine the efficiency and effectiveness of the response when an outbreak happens. The preparedness phase would be embedded in the overall strategy of promoting water, sanitation and hygiene as these are critical components in preparedness against AWD / Cholera. A synopsis of the key components in the preparedness and response phase have been presented in the following pages. For details on the phases and recommended interventions please refer to Annexure 4
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Preparedness Phase 1. Enhancing Coordination through the Sub Committee on Health Promotion: Effective prevention, preparedness and response for cholera requires co-ordination and communication across sectors and at different levels. Under the leadership of The Ministry of Health, the Health Promotion division would coordinate the working of the sub - committee on health promotion, with representation from ministries / departments such as Community Health, Public Works, Land, Mines and Energy, Nutrition, Education, Internal affairs, Information Culture and Tourism and development partners. Similar committees would also need to be formed at the county and district levels 2. Development of a communication plan: The plan would define the objectives, the approaches, the resources required including human resources, the participant groups and the means to ensure dialogue /deliver the messages. 3. Co-ordination across borders: Liberia shares a long border with countries have a history of cholera outbreaks like Sierra Leone, Guinea and Côte d’Ivoire. Hence co-ordination will be required between government authorities at national and local government levels with these countries to prevent the spread of Cholera across borders. 4. Investing in communication research: The plan should begin with a formative study and assessment to identify the knowledge, attitudes, perceptions, beliefs and practices of the people on the issue and understand the different means for bringing about change. However on-going assessment, monitoring and listening to communities will also be vital during the outbreak. 5. Identifying communication channels: Communication channels would need to be identified in advance. It is advisable to use both interpersonal methods and mass media methods for addressing cholera outbreaks. 6. Standardization of messages, preparing action oriented communication materials and keeping them ready for dissemination: Messages and materials that have been pre-tested would have to be developed, produced and prepositioned in advance so that during an outbreak they can be immediately distributed in the field. This will save precious time and resources. 7. Training service providers / community level workers on Interpersonal Communication (IPC) skills: In times of stress and trauma caused by an outbreak, health workers and specially community level communicators such as Animators, GCHVs, HHP etc. need to possess and maintain good IPC skills to inform, motivate, counsel and encourage affected people and communities. Thus training them on IPC skills would be an important preparatory activity. 8. Engaging communities in preparing and planning for emergencies: Supporting communities in areas particularly vulnerable to cholera, to develop community action plans themselves would be a key preparedness activity. This would ensure effectiveness as well as sustainability. 9. Testing the communication plan by mock drills and exercises: Even very well developed communication plans for emergencies may fail during actual implementation. Therefore, they need to be pre-tested through mock – drills to ensure that they work well during emergencies.
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Response Phase 1. Developing a communication protocol and partnerships for collaboration: A plan would need to be developed with key partners which outlines how communication efforts will be coordinated. This would help effective implementation and also help prevent and manage rumors, misinformation and unwanted results that often happen during outbreaks. 2. Participation in sectoral rapid assessments: When Health and WASH assessments are conducted in the initial phase of an emergency, it is critical that the assessments also identify any high risk practices that have implications for communication among affected caregivers and communities. 3. Conducting a rapid appraisal of communication channels and resources: Soon after an outbreak is announced, efforts would need to be made to find ways to reach the vast majority of affected people quickly with information and key messages. In many ways, the rapid appraisal might be a validation of the channels identified in the preparedness plan. 4. Revisiting and activating the detailed communication plan: Based on the preparedness plan, the details of the implementation of the communication initiative(s) would have to be established and activated. 5. Focusing on re-establishing existing behaviors and norms: In the initial phase, the focus would be on re-establishing positive behaviors and social and cultural values that existed prior to the outbreak. However, depending on the situation, emergencies might also provide opportunities to promote new behaviors. 6. Forging additional alliances for communication: The outbreak might provide opportunities to build additional alliances to include relief workers, service providers, journalists and others so that they are able to directly support desired behaviors of affected people. 7. Facilitating community and children's participation: Through established community level committees, pro-active efforts would need to be made in creating opportunities for affected families and communities, including children and young people, to participate in the response. 8. Working with the media: As a priority, decision makers should come together and decide on what to communicate to the media. The communication would need to be frequent and effective through a dedicated spokesperson. 9. Listening through Dialogue and Tackling rumors: During an outbreak, it would be crucial to set up a rumor tracking system to identify, investigate and address misperceptions or misunderstandings through community workers, and the media. 10. Reaching the poorest and those in particularly vulnerable, hard to reach or special circumstances – Equity perspective: Particular attention should be paid to people who are more vulnerable or marginalised in a given context or those who are harder to reach through special outreach activities. 11. Dealing with psychosocial impact: Cholera can have a variety of psychosocial impacts. People may have strong feelings of fear, insecurity and helplessness; patients may be stigmatised; people might not be allowed to undertake usual funeral and mourning practices. Thus community workers would have to be trained to deal with this and community leaders oriented to help reduce stigma in the community.
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tion, Monitoring and Evaluation
Let’s Implement, Monitor & Evaluate!
CHAPTER 5
Implementation,
Monitoring & Evaluation
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Implementation
he implementation would be coordinated by the Health Promotion Division of the Ministry of Health and Social Welfare though the coordination committee on WASH promotion with representation from stake-holding ministries/ divisions such as Public Works, Land, Mines and
Energy, Environmental Health, Nutrition, Education, Internal affairs, Information Culture and Tourism and partners. Similar coordination mechanisms at the county and district level under the leadership of the County Superintendent and District Commissioner would need to be formed. Along with the national plan, each of the counties would have to develop a county communication plan. Suggested implementation templates for the national communication plans and county communication plans have been provided in annexure 6
Monitoring and Evaluation
system for monitoring and evaluation of the Communication Strategy is critical so that programmatic improvements can be made as needed. Monitoring provides insight into how well a response or planned set of activities is being implemented. It is part of the evaluation
process. Evaluation is a continuous process, done periodically, i.e., at each stage of the programming cycle. It offers a comprehensive review of whether a program or an emergency response is achieving its short term results and longer-term goals. Continual and careful monitoring of relevant indicators and processes generates information for evaluation and more importantly, for corrections that may be needed as the program or an emergency response unfolds. An M&E system refers to a textual, graphical and/or numerical data system used to measure, manage and communicate desired performance levels and response achievements. M&E systems are often based on a combination of evaluation types. A detailed M&E framework has been provided in Annexure 7
Type of evaluation
Broad purpose
Main questions answered
Baseline Analysis/ Formative Evaluation Research
Determines concept and design
Where are we now? Is an intervention needed? Who needs the intervention? How should the intervention be carried out?
Monitoring/Process Evaluation
Monitors inputs and outputs; assesses service quality
How are we doing? To what extent are planned activities actually realized? How well are the services provided?
Outcome/Effectiveness Evaluation
Assesses outcome and impact
How did we do? What outcomes are observed? What do the outcomes mean? Did the response make a difference?
It is recommended that that in order to validate key knowledge, attitudes, perceptions, barriers and practices related to water, sanitation and hygiene, a formative study be carried out. This would need to be supported by a KAP baseline before the strategy is rolled out. Further, a midline and end of term assessment would also have to be carried out to establish effectiveness.
T
A
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If a cholera outbreak occurs and the formative and KAP have not been carried out, in order to obtain data on household and community hygiene practices it will be necessary to carry out household surveys using a random population sample. It can be a challenge to accurately measure some outcomes e.g. the proportion of people who are washing their hands with soap. Self-reports of hand washing often overestimate actual rates and so should be supported by structured observations and spot checks. Data should therefore be cross-checked using a variety of tools (triangulation). Some of them could include:
Discussions with families
Interviews with key informants
Focus group discussions
Observations
Physical measurements
Responsibilities for monitoring and evaluation Undertaking joint monitoring and evaluation with partners and across sectors in support of the programme would be extremely important. Clear indicators and means of verification would have to be identified and agreed upon. Standardized tools and formats for monitoring would have to be developed. Although different agencies might me involved in carrying out particular types of studies and evaluations, they would have to be carried out in consultation with all stakeholders. This would ensure coherence and minimise duplication of efforts. Further, efforts should be made to disseminate findings to all stakeholders including communities.
Involving communities in monitoring Involving communities in monitoring activities can be a useful way to mobilise action. Monitoring plans can incorporate indicators that different participant groups can help to monitor. For example:
Children could do structured observations outside the school latrines to identify hand washing rates.
Communities could monitor the cleanliness of public latrines or the presence of hand washing facilities.
Where chlorine levels in drinking water are monitored at the household level, community members could help to do this and the results could be shared with them as a way to trigger discussion on remedial actions.
It is important to instigate a system for on-going dialogue with communities to be able to actively listen to their concerns. This will help to identify problems with the response, such as groups that are not being reached, misconceptions and misunderstandings, abuses of power and poor quality interventions from partners. Standards of service provision both in the community and health settings should be made available publicly and every effort should be made to be open to suggestions for improvements. Regular discussions (weekly then monthly) with different participant groups are useful and these could be supplemented by the use of suggestion boxes, phone-ins or complaints mechanisms.
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Need more information?
CHAPTER 6
Annexures
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Annexure 1: Behavioral Analysis A study on Nutrition and Hygiene Knowledge, Attitudes and Practices was carried out in the Southeastern counties of Maryland, Grand Kru and River Gee by the Danish Refugee Council in 2009. These three counties are considered to be the least developed and isolated counties of Liberia. The study provides important insights into understanding issues related to Water, Sanitation and Hygiene in rural Liberia. The logistics of practicing Good Hygiene appeared to be a major issue. Soap was normally kept inside the home, in fear that it would be stolen. Therefore, when it was needed after toileting, the individual would have to fetch it, get water and after use return the soap inside the home. When eating in the home, people threw their food garbage on the floor, and then swept several times a day to get rid of it because there was no extra bucket to use as a garbage pail. Often drinking water containers were not covered, because the type of container used did not have a cover. The same drinking cups were used by all because there was not enough money to buy a separate cup for each person. Household cleaning and hygiene practices were therefore marked by cost and energy reducing activities. During community meetings, some women reported that they did not have money to buy soap. While the majority of families observed, had soap, it was clear that it was sometimes hoarded and that tasks that were not a priority, e.g., washing hands, were often skipped to allow the soap to last a bit longer. Many people though, might have been slightly exaggerating the extent to which they were not using soap because of the cost. The local soap, costing about 10LD (approximately US$0.17), is within reach of the majority of villagers. Many families who said they did not have money for soap to wash hands, were washing pots/bathing with soap and paying school fees, suggesting they had disposable income. Many of the villagers reported that they did not know the reason why they should wash hands with soap, but yet the majority was using soap to wash clothes and pots/dishes, meaning they knew that it got things cleaner than water itself; however, other factors were preventing them from washing hands with soap. The traditional way to wash hands in these communities is for several people to wash hands using the same bowl and water. If, at communal events, individuals choose to wash their hands separately, they are often thought of either as “orphans”or as trying to separate themselves from others. On the survey, almost 80% of the sample reported washing their hands with soap after using the latrine, 69% before cooking, and 69% before eating. Only 16% reported washing hands or breasts before breastfeeding their children. Of those who reported washing their hands with soap (for any reason), only approximately 33% reported washing hands with soap most or all the time. The percentages were similar across gender. More than 80% reported washing hands one at a time, rather than using the traditional method of washing many hands in one bowl. Among those who did not know the reason why they should wash their hands with soap, only 18% washed their hands with soap most or all of the time. In comparison, for those who reported knowing the reason why they should wash their hands with soap, 42% washed with soap most or all of the time. This suggests that there is some correlation between knowledge and behavior on this item. The main reason why people did not wash their hands with soap was because it is not around/available when they are ready to wash hands (60%). Almost 99% of the sample reported keeping their soap inside and bringing it outside to use when needed – this explains lack of availability of soap when it is needed. They keep the soap inside for fear that it will be stolen. Other reasons why soap was not used included because there was no money for soap (20.4%), and thinking that using soap was a waste of time (10.2%). Almost 52% of the sample had only one piece of soap that they used for all purposes. Of the 62% of the sample who said they knew the reasons why soap should be used when washing hands, 94% said it was either to kill germs, avoid disease or to get hands clean/er. Besides washing
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hands, 94% of the sample reported using soap to wash clothes, 90% for bathing and 77% for washing pots and dishes. A large number, though not the majority of households, had dish racks, on which they kept their dishes for drying and storage. While the clean dishes were kept clean on the dish racks, dishes were usually washed on the ground, generally by young girls, using one pan to soap and wash the dirty dish and another pan with clean water to wash off the soap. In the majority of these homes, the floor is made of compacted dirt. In only a few homes is the floor made of concrete. In these communities, lives are spent on the dirt, sitting, lying, playing and eating from the ground. It would be difficult to get across the message that dirt itself is bad, as children play and eat from the ground. In terms of Drinking Water, from all reports, pump water was much preferred over drinking creek water. The most common complaint was that there were nonworking pumps in the villages. The vast majority of villagers appeared to have accepted pump water as the more appropriate choice, though there were still some individuals who reported preferring creek water because their forefathers used it, or because it tasted better or colder than pump water. However, the main issue was the problem of availability. When the pumps were originally built, generally two persons in each village were trained on how to fix the pump, and tools were left with these persons. What was found in the villages was that either the persons who had been trained were no longer there, or if the individuals were still there, they did not have the tools to fix the pumps. Location was another issue in pump usage. In many villages, if a pump was not located within 3-4 minutes’ walk of a household, people would simply choose to get water from the creek. There was also the issue of “ownership.” Villages are generally divided into zones or quarters, each with its own sense of what belongs to them and what does not. Privacy may also be an issue in the use of wells. For example, women prefer not to use a well that is in the center of town, because they take the time when walking to the creek outside of town to discuss private matters amongst themselves. Even if people say they drink primarily pump water, when they are out on the farm, they almost certainly are drinking creek water – no one brings a bottle of water with them when they are farming. Carrying water to the farm is not a priority and generally is completely out of the range of the normal experience of an average villager. On the survey, almost 60% of the sample reported getting their drinking water from a protected hand or foot pump; almost 40% reported using creek water. Approximately 64% of those who used creek water had a pump available, but chose not to use it. The main reasons were because the pump was too far from their home or because the water was salty. Boiling Water is a task that people openly admitted they will not do. It took too much effort, firewood, and they did not really understand the use of it. Also villagers seemed to think that after boiling water, it should be drunk while still hot. While the women said that boiling water was something that they were not used to in their culture, it was found that it was common for women to heat up water for their husbands, children, and often themselves for bathing at night, suggesting that there was at least some practice with using heated water. 69% did not know the reasons why water should be boiled. There was a significant difference in knowledge between men and women on this item – 44% of men compared to 19% of women knew the reasons why water should be boiled. Of those who knew, almost 99% correctly identified killing germs, or avoiding sickness as the main reason to boil pump water. These results are highly informative, given that it is women who generally perform the household duties related to hygiene, yet they appear to be far less knowledgeable than men on this issue. In terms of Toileting, majority appeared to prefer using latrines, if available. Many of these villages had been targeted for latrine building by a number of NGOs, and many of the latrines were in need of repair. However, it was clear that people expected NGOs to fix the latrines. Although there were
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some villagers who reported preferring to use the bush for toileting, e.g., one man who said that when using a latrine he didn’t feel “free” and that he didn’t feel the breeze and fresh air as he should when toileting, the majority appeared to prefer using a latrine over using the bush. The main barrier to using a latrine was that none were available. This lack of availability occurred for several reasons: in some villages the chiefs took the latrines as their own and put padlocks on to prevent others from using; in other villages, the majority of persons reported that there were no latrines in the village, though there were reports that some individuals had latrines that were not open to non-family members; and in others, the latrines that were built were damaged and could not be used. There were some reports that, in traditional culture, the toileting locations of men and women were kept very separate. Apparently some latrines for men and women were built next to each other, which may have contributed to non-use. Approximately 51% used a latrine. Of those who did not, the primary reasons were: there were no latrines close to the home (43%), or there were no latrines in the village (43%). In the villages where some villagers stated there were no latrines, it should be noted that there were several individuals within the village who reported having access to a latrine. For those individuals who did have access to latrines, 58% put locks on their latrines, primarily to keep out others who were not family, and also to keep out children. In the households with latrines, 37% prevented their children from using the latrines, primarily because the children were too young and may fall in. In terms of Knowledge about Diseases 60% reported they did not know what causes malaria, 55% did not know the cause of diarrhea, 78% did not know the cause of cold/cough, and 51% did not know the cause of skin diseases (e.g. craw-craw – scabies). Knowledge of the correct vs. incorrect causes of these diseases was analyzed. When viewed from the perspective of the entire sample, only 27% of the sample correctly knew the cause of malaria, 40% for diarrhea, 4% for cough/cold, and 43% for skin diseases. The top three illnesses for the village in general and for children were the same: malaria, cold/cough and diarrhea. To treat their various illnesses, 75% of the respondents said that their first choice of treatment would be to go to a clinic or hospital; 19% said they would first try natural herbs/bush medicine and 6% said they would first buy medicines. Of those who said they would first go to the clinic/hospital, when asked if going to clinic did not work, what else would they try – only 26% of those who responded said they would go back to the clinic. A much larger number, 57%, said they would try natural herbs/bush medicine. For the entire sample, when asked what they would do if their first efforts did not work, almost 40% said they would go to clinic/ hospital, and another 40% said they would try bush medicine. Children are used for the majority of small tasks in the household – washing dishes, helping to take care of babies, carrying water, assisting in carrying firewood, sweeping, etc. As with the rest of the family, however, issues of hygiene are often not enforced. Playing, sitting on, rolling around in and generally being in the dirt is part of their daily experience. However, while parents are quite aware of the childhood illnesses which contribute to the high levels of morbidity and mortality in these communities, the majority do not know of the connection between hygiene and disease or nutrition and disease. For example, there are many common misconceptions about the causes of malaria (e.g., hot sun, bad food), diarrhea (e.g., drinking hot/warm water), and colds (e.g., long walk, smoke). These will need to be addressed. There is the assumption that the majority of children will survive, even with the old, traditional ways; therefore there is not a compelling reason to do more than they are currently doing. There is an interesting Syncretism of old and new practices in the life of every villager. It is not unusual to see one family drinking pump water at home, but creek water out on the farm; washing hands with soap only sometimes after using the latrine. The existence of these practices side by side, suggests that the understanding and value of these practices are slowly being incorporated by a large number of villagers in these communities. The continued uptake of the newer, more hygienic
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practices will largely be determined by the availability and ease with which the practices can be incorporated into everyday life. It is possible that if the connection to illness were better understood, villagers would be more likely to practice and adhere to better hygiene practices. It should be noted that there was very little difference in hygiene and nutrition practices in average vs. relatively richer households. Vulnerability Factors also need to be understood. Liberians living in villages experience clearly defined seasons of harvest and hunger when most / all of the rice has been consumed and families generally subsist on Cassava production. In general, the harvest season lasts from September to January and hunger season from March to July with the worst being experienced from June to July. The average number of meals eaten by respondents during the hunger and harvest season were 2.06 and 2.63 respectively. During such seasons of hunger, it might become even more difficult for villagers to practice appropriate hygiene such as boiling water or washing hands with soap. The most common uses for extra money were for food, clothing, and also saving for the future. Almost 79% of the sample engaged in farming as the main source of subsistence, and 10% in petty trading. Approximately 4% of the sample said that they relied on their husbands. Exploring Social Norms revealed that approximately 60% of the respondents said they did not know if other villagers washed their hands after using the latrine, before cooking, before eating, and before breast feeding. Between 20- 25% reported villagers washing hands for latrine, cooking and eating, with only approximately 8% prior to breastfeeding. The most common times reported for washing hands, as required by family or culture, was before eating, after the latrine and before cooking. The dimension of Gender is also critical. Almost 75% of the sample reported contact with persons who spoke with them about washing hands, using soap, nutrition, or similar subjects. When compared by gender, 18% of the men had not received any nutrition/hygiene education compared to 32% of the women. These statistics suggest that women are approximately twice as likely not to have received nutrition/hygiene education, compared with men whereas it is more often the women who are the ones maintaining hygiene at home. However, it was found that women were generally easier to organize and more effective in community projects. Men were generally better able to communicate in English, and were better educated. When people were told to gather, the leaders generally excluded women to “keep the knowledge for themselves.” Women generally did not talk in meetings when men were present, especially if their husbands were present. A Cassava farming project by the DRC in Diabeville has been very successful. Participation is 90% female and there is a chairman and a chair lady leading the group. DRC wanted the project to majority female, to allow for a sense of empowerment among women. Based on past experiences where men were the main recipients, money generated from the crops was spent on themselves. In contrast, the women would spend incomes on the family. This example further emphasizes the need to focus on women. Cultural Practices regarding hygiene were variable, and not consistent even within one village. For example, in some communities, it is the practice to wash hands after returning from the fields, but as a practical matter, many may not do so, unless they actually see dirt on their hands. There were reports that in some communities there were taboos against drinking pump water, for example, women may be warned against pump water because it will make them sterile. However, in the communities that were visited, there seemed to be overwhelming acceptance of drinking pump water. When pumps are not available, there is resistance to boiling creek water, as many villagers believe that creek water aids in conception. However, the main issue appeared to be one of logistics, rather than culture. It may be confusing to separate the effects of culture from those of simple practicalities or lack of interest. For example, an old man said that he did not drink from the pump because creek water makes people strong, and his grandparents had always drunk creek water.
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However, after spending some time with the old man, it was discovered that the old man was not able to walk all the way to the pump, and did not want to ask anyone to help him to get the water. Culture plays a potentially major role in the perceived lack of willingness of these communities to adopt nutrition, hygiene and agricultural practices that could conceivably improve their lives and health. This lack of willingness may have historical roots. Members of these communities have adopted modern technology, e.g. radios, motorcycles, and cell phones but in some instances, however, there may still be a cultural bias, which cautions against the uptake of new things too quickly. It is more likely that new practices, e.g., hand-washing, take more time and effort than the old ways, and hence there is a reluctance to put in the work needed for these new practices. Also, in these villages, it is far easier to simply revert to older traditions, e.g. toileting in the bush, and using creek water, rather than putting effort into fixing latrines, putting money together for pump repair, etc. The almost 14-year war, which ended only in 2003, and the consequent history of receiving support due to refugee status, has also had an impact on people’s willingness to initiate and do new things on their own. After 14 years of receiving support, it is often difficult to start over again; psychologically, there may be the belief that war could easily restart, and people could lose everything. Witchcraft and a belief in the supernatural is an integral part of the life of nearly every Grebo and Kru individual, and permeates every aspect of life, including nutrition and hygiene practices, health behaviors, agricultural efforts, and determines who succeeds/advances financially in life, and who does not.. For example, there still a strong belief that sickness is related to the supernatural. Although the majority of persons have a strong belief in the power of Western medicine, sometimes if the first dose of a medicine does not work, there is often an instant assumption that witchcraft was the cause. Funerals, and the feast days surrounding them, especially if it is for an important man, may last for an extended period. In the past, bodies used to be kept for 1-2 months at a time (significant if the death has been due to cholera). More recently, the government has dictated that the activities surrounding funerals not go on for more than three weeks; however, during this time, very little work is done, and certainly nothing that is not necessary for survival. Hierarchy and Participation, like culture are overarching issues that influence the potential of programs to succeed. An individual’s position in village society is determined by the closeness of his linkage with those in power. Village systems are not unlike other social and governmental system around the world. They are set up to maintain and improve the lifestyle of those already in power, generally to the detriment of those at the lower end of the social scale. In village societies, there are generally two ways to improve one’s position, either to get a job with the government, or to have a position within the village that allows one to control the flow of “supplies” to the village. In this sense, the village chief and the village representatives/contact persons for NGOs have quite a bit of influence in determining who benefits from the implementation of various projects. Usually projects have contact persons also serve as the focal point for communications, as organizers, and often participate in the distribution of supplies. Because projects must depend on the good relations of the leaders of the communities, the organization accepts the will of the people when it comes to the contact person. In some cases, the contact person and other leaders have utilized their position to create benefits for those in their favor, including family and friends. Perhaps attempts can be made to introduce processes that ensure a fairer distribution of opportunities to participate and benefit from the programs. The authority of contact persons and other leaders to choose persons for a range of activities often result in participants who may not be appropriate for or representative of the community.
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The hierarchical system in each village also affects the level of participation and potential for the success of projects in each of these villages. Among the elders and leaders in the community, there is a perception that it is their natural right to receive the benefits of any project. For example, in Chinakale, one of the chiefs has put a lock on what should be the community latrine. There is an assumption that if surveys are being done, or NGOs are visiting homes, supplies will somehow find their way to the village, and these men wanted to ensure that they received some of the benefits. Suggestions on the way to counter this have been to plan for the meetings to be open to all the community, not just with the leader, to ensure a more open environment for the project. Further, building a consensus and deciding upon a leader process may be more effective It is important to understand Community Perceptions towards a particular project as well as assumptions of the implementer’s motivation to initiate projects. Communities are aware that the implementers are interested in the success of the projects and that they themselves will do as much as possible to ensure project success. If they are offered a project, they will not say “no” because even if they have no interest in the product, or if they are currently busy with other farms, there will be tools and other supplies that will arrive as a result of the project. The communities know that they have to demonstrate their efforts to start a project, but that they may reduce their efforts after that because communities know that the implementer cannot simply walk away from the projects. The failure of communities to live up to their commitments when accepting projects usually goes without consequences. On a community level, villagers in this region generally are not used to working together. Therefore the idea of coming together for an initiative appears simply outside their range of experience. Rather, they have been used to various NGO interventions such as food for work, payment to clear roads, and especially “sitting fees” for attending workshops, even when these workshops will be of direct benefit to them in the future.
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Annexure 2: Field Visits, Discussions &Observations Field Visits to WestPoint in Monrovia which is an urban slum revealed low knowledge, risk perception and poor practices related to water, sanitation and hygiene. The general living conditions were found to be unsanitary, with overcrowding and extremely poor drainage. Defecating into plastic bags and disposing them in the garbage is common practice. There is a community toilet, but that is built over the adjoining river and feces freely fall into the river below. People do not send their children there as it is considered unsafe for them. Fish from the river is used for eating, increasing the chances of infection and disease. Further, during the visit it was observed that fish was being cleaned and prepared right next to the toilet, on the banks of the river for selling in the local market.
People collect water from hand-dug wells for washing clothes, brushing, cleaning utensils and bathing. Because most of the land is reclaimed from the river, the water table is extremely high. The wells are only around 4-5 feet deep. This poses a huge risk of contamination from the river water. Children, who are unsupervised, also drink water directly from these wells. Families buy drinking water from water vendors at the rate of around 50-60 Liberian dollars during the dry season and around 30 Liberian dollars during the rainy season for 5 gallons. However, the source and quality of the water is questionable. It is transported in large jerry cans on a makeshift trolley and
these cans are not well maintained. The water is stored in 5 gallon Jerry cans and these are supposedly cleaned before fresh water is poured into them. Water guard has been distributed for free by PSI in this community and people add it to their drinking water, which they store in 5 gallon jerry cans. The free distribution is only for promotional purposes and once they run out of it, they will have to buy it. However, it is not distributed or easily available in the market. Many people in the community do not have a regular source of income and hence being able to afford the money required for buying drinking water on a regular basis may not be possible. Hence they sometimes end up drinking the well water. Discussions revealed that they may be sometimes boiling the water before drinking, but the duration for which they should do so, is unknown to them. Further, coal is used as fuel and in a resource constrained environment, using it for boiling water does not seem like a preferred option. Food is sold in the open in the marketplace and is frequently sat on by files. There is a garbage collection service of the corporation, but many cannot afford to use it as they have to pay 25 Liberian dollars a week to use it. So, garbage sometimes piles up. The most common reasons given by people for not following recommended behaviors as mentioned by the NGO FAAL, working in the area are: “We have been doing these things for very long now and nothing has happened. So why should we change?” “There are no germs for Africans. Germs only affect the foreigners” “Hands that appear clean are clean and need not be washed”. The NGO has been working in the area for the last four months, primarily doing safe water, sanitation and hygiene promotion through household visits and film shows at ‘Video Clubs’. According to FAAL, working with religious leaders, women’s groups, traditional healers, drama groups and using communication materials and tools would further help them in their work.
FGDs at WestPoint, Monrovia
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Field visits to Taenimai village in Garowularo District of Grand Cape Mount County revealed a high level of community participation and ownership in WASH activities. An NGO, FAAL had been working in the community till a few months back. The village has around 650 people. There are four hand pumps, out of which two get dry during the summer months. The two that get dry were installed many years back by Plan when they were working in this community. The other two were installed by FAAL in 2010 and 2011 respectively. There is a creek nearby, but people take water from the tube wells for all purposes ranging from drinking to cooking to bathing and washing dishes. On being asked why they do not use creek water, they mentioned that creek water is dirty and unsafe for use, whereas the tube well water is safe. FAAL had distributed Aquatab in this community and people were using it to purify their drinking water, but now that it is finished, they drink water directly from the tube well. The village has three community toilets and some houses have individual toilets as well. The village school also has separate toilets for boys and girls. The toilets were well maintained, covered and traces of ash could be seen around the pan, indicating that people regularly cleaned and maintained them. Open defection is not a problem in the village and everyone uses the toilets. Small children defecate into Potties which are then emptied out into the toilets. Families are given the responsibility of cleaning these toilets on a rotational basis and if any family happens to fail to clean them, during their turn, they are fined 50 Liberian dollars by the village chief. However, this has not happened till date. On being asked about hand washing practices people reported that they regularly wash their hands with soap/ashes/lime before eating, cooking, after defecation and after cleaning a child’s faeces. There are ‘Tippy Taps’ for washing hands at many places in the village. There seemed to be good knowledge about the connection between unsanitary/unhygienic practices and diseases. The last case of cholera in the community was around five years back. Since then, they have not had any cases of AWD or Cholera. However, there are some rare cases of diarrhea. The village was very clean and all the houses were permanent in nature. The villagers had come together to build the village school. On being asked how their village was doing so well in terms of WASH, people responded by saying that through the intervention of the NGO, they realized the importance of sanitation and hygiene and the fact that they need to collectively work to ensure that the gains in their village were sustained. The school teacher reported that he had recently started hygiene education classes in the school, but has no money to provide soap for hand washing in the school.
FGDs at Taenimai village, Grand Cape Mount
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Annexure3: Promoting WASH- Key Segments & Interventions
Segment 1: Communication for Promoting Social and Behavioural Change among Families and Communities This segment would focus on using various means of communication to reach families and communities both directly through interpersonal / social contact and indirectly through mass and mid-media in order to help change knowledge, attitudes, beliefs, mind sets, perceptions and practices. Some of the key interventions in this segment would be: 1. Radio / Television Spots Radio and Television spots would be developed and aired, focusing on promoting key water, sanitation and hygiene practices and the risks associated with not following them. The focus would however be on using radio as radio has greater penetration and reach as compared to television. Apart from the commercial radio stations, Liberia has a large number of community radio stations spread across different counties. These would be used for airing of the spots. The UNMIL radio could also be used. The spots would have a positive, motivational feel aiming to address both knowledge gaps as well enhance self-efficacy among listeners in order to be able to try the recommended behaviours. The spots would also help in creating public visibility around the issue. 2. Radio Soap based on Entertainment-Education (E-E) While the spots would highlight some key issues/ behaviours, there are several issues in water, sanitation and hygiene that require longer duration programming. Thus it is recommended that a weekly, 52 episode radio soap be developed and aired. The soap would be based on E-E principles making it informative, inspirational, engaging and entertaining. It would have real, believable characters that follow a trajectory of ups and downs but are ultimately able to achieve positive outcomes in their lives by adopting safer water, sanitation and hygiene practices. The radio soap would have an interactive component through phone-ins SMSs and panel discussions that would help people resolve queries that they have and also better engage with the programme. Also, community linkages would be created, through the formation of ‘Listeners groups’ which would facilitate community listening and mobilisation. Further, embedding messages in existing popular shows on radio and television could be explored. 3. Working with Cellular service providers Mobile telephony has reached large parts of the country. With increase in network coverage area, substantial drop in the prices of handsets and call charges, even in very remote, rural areas people are nowadays using mobile phones. Further, in terms of the advertising space on television, a huge portion is occupied by advertising by cellular service providers. In recent times, there have been instances of cellular companies in many parts of the world, taking up public service campaigns as part of their corporate social responsibility as well as image building activities. It is proposed that the following could be done in collaboration with a cellular service provider as part of their corporate social responsibility as well as social business plan. A. TV/Radio spots - The cellular service provider could support the development of co-branded
television and radio spots mentioned above. It would facilitate the development of the public
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image of the company as a socially conscious and responsible company. The ‘self-efficacy’ route mentioned above would also aid in the process. The programme would benefit in terms of the huge exposure that would be generated through the airing of the spots on national as well as county level channels/ community radio stations
B. SMS – Push SMS’s could be sent to mobile subscribers with messages having a definite call to action such as “Am sure you have washed your hands with soap after doing ‘pupu’ today right?”. Further, recorded voice messages using a celebrity could also be used.
C. Outdoor activities such as mobilizing youth in market places, schools and colleges around the issue could also be promoted along with the company’s promotional activities.
4. Outdoor Media and IEC materials The IEC materials/outdoor media will support interpersonal communication and give credibility to the household and community level communicators. Outdoor media in the form of hoardings at the capital, county and district level at strategic locations and wall paintings at slum/ town/village level would be put up in order to create visibility as well as an enabling environment. IEC Materials such as posters and banners would need to be developed and supplied to the counties / districts well in advance. The materials would need to be put up according to a predetermined micro plan at strategic locations and not on an ad hoc basis for ensuring maximum effectiveness. In the development of outdoor media and the IEC materials, the following principles will be followed:
Branding – All Outdoor media and IEC materials in support of the campaign would need to follow a branding guideline i.e. all materials should have the same ‘look and feel’. It should not seem that the materials are not connected with each other.
Design - IEC materials should be taken as part of an entire package and not seen on an individual stand –alone basis. The material would need to have recall value, brand identity, and easy recognition and association with the campaign. The materials would also need to be field tested before production
5. Video Clubs Video Clubs are extremely popular in Liberia. People come together at these clubs to watch football matches, movies and also exchange information and gossip. These clubs would need to be partnered with as they provide a ‘captive audience’ with whom a dialogue on safer water, sanitation and hygiene can be ensured. Before the beginning of a movie or a match, a film promoting key behaviours could be screened following by a discussion around the same. It would also be a good opportunity to demonstrate skills such as the correct way to wash hands, purify water etc. and also hand out communication materials. 6. Community Drama Community Drama as a local media can be effectively used to disseminate key information as well as promote behavioural change. Further, it would also prove effective in media dark areas to reach out to families and communities. Community drama is entertaining, engaging and if followed by a well facilitated discussion, can help promote deeper understanding and positive attitudes among audiences.
7. ‘Town Criers’
‘Town Criers’ serve as an important source of information for communities. They usually go from house to house making announcements about key events happening in the town/ village. They can be used to disseminate information about mobilisation activities happening in the community as well as key messages.
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8. Working with Beauty Parlours/ Salons and Barbers
Beauty parlours and barbers are a common sight, especially in urban areas. People spend a considerable amount of time there as it provides an opportunity to talk to other people and socialize. Parlour owners and barbers could be oriented and motivated to talk to their customers about the importance of sanitation and hygiene, put up communication materials in their shops and also hand out some literature.
9. Working with Gospel Musicians / Popular singers
Both gospel and popular musicians are listened to in Liberia. They could be partnered with to include themes on water, sanitation and hygiene in their songs.
7. Communication through GCHVs, HHPs, TTM and Animators Community level frontline communicators provide a great opportunity for carrying out interpersonal communication with families and communities. There is no better way to counsel, motivate and follow-up with families and communities than interpersonal communication as it provides a platform for two-way dialogue in which people can have their doubts, queries, concerns and needs addressed. Thus training community level workers on interpersonal communication skills in order to effectively communicate with families and communities would be carried out. Further, they would also be provided with a ‘Toolkit’ that would help them in their interpersonal communication. 8. Communication through Nurses, Physician Attendants, Environmental Health Technicians and Doctors Service providers are also a group that come in contact with families and are a respected and reliable source of information. Directives would need to be provided to them to discuss with clients their water, sanitation and hygiene behaviours while providing them clinical services as often, reasons behind illnesses lie in poor hygiene and unsanitary practices. Communication materials would also need to be provided to them to put up / keep for distribution in their facilities. 9. Communication through Teachers Teachers form the basis of the education system. Issues related to infrastructure often do not have the kind of impact that the quality of a teacher has on the overall development and well-being of children. Children often look up to teachers as role models and try to emulate them. Thus promotion of good habits among children would be a key responsibility for the teachers. As part of the strategy, a great deal of work in envisaged with and through the teachers. Workshops with teachers on their role in promoting good sanitation and hygiene would be carried out. They would be provided with the necessary tools and materials to integrate components of sanitation and hygiene in the school learning environment. Teachers would also be motivated to meet parents of children and community elders/ leaders to encourage them to adopt positive behaviours. 10. Working with Children Interventions for children often neglect the importance of involving the most important stakeholder – children themselves. Working with and motivating children can greatly contribute towards bringing about change within themselves as well as in their families and the larger community. Some activities with children proposed as part of the strategy are:
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A. Peer Counsellors and Buddy Pairs
Peer groups play a very important role in shaping personalities as well as determining life preferences and choices. Sanitation and Hygiene behaviours among children are often influenced by peers. If a child sees that his or her peers are not practicing positive behaviours related to sanitation and hygiene, he or she would also not feel the need to do the same. Whereas if his or her peers understand the value of sanitation and hygiene, and practice them, the child would also feel motivated to do the same. Teachers would be encouraged to identify (maybe on a rotational basis) ‘Peer Counselors’- students with leadership skills and qualities to counsel/ follow-up with children. Other children would be grouped into ‘Buddy Pairs’ with each having the responsibility of looking after each other. (These would have to be done based on a consultation with children). ‘Buddy Pairs’ would keep motivating each other to practice recommended behaviours. The progress of these pairs would be monitored on a regular basis by the teachers as well as the ‘Peer Counselors’. The ‘ Buddy Pairs’ would be encourage to maintain a weekly diary in which they would note the progress being made by their buddy as well as problems being faced. In addition, they would also note down the steps that they have taken/ advice given to help their buddy. At the end of each week, the buddies would share their notes with each other. These diaries would be reviewed on a periodic basis by the teachers and /or the ‘Peer Counselor’- whoever, the buddy pairs are comfortable with. Well performing ‘Buddy Pairs’ would be publicly acknowledged. It is envisaged that this system would make children feel that there is someone who if supporting/ following up/ monitoring him or her as often, the lack of constant support /follow-up and reminders could result in reversal to old practices. Also by being responsible for another child and helping the child maintain his or her positive behaviours, children would be able to help themselves sustain their behaviours as often, a good way of ensuring responsible behaviour is to give responsibility. The sense of, ownership, control and pride that this process would generate, would help children maintain their positive behaviours.
B. Special Classroom Activities
Teachers would be encouraged to carry out special classroom activities to promote sanitation and hygiene among children. Classroom activities such as discussion around vignettes or picture stories, stories with a gap, demonstrations etc. would need to be carried out.
C. School Health Clubs
Some schools already have health clubs where children are engaged in health promotion activities in their schools. This would need to be stepped up and children motivated to also carry out community mobilisation activities. Further, clubs for out of school children would also need to be formed.
11. Working with Community Influencers and Religious leaders
Almost all communities have individuals / institutions that community members look up to and trust. Identifying these individuals / institutions (some of them could be having religious affiliations) would need to be done and used strategically for community mobilization as well as need-based family –level engagement. Paramount Chiefs, Clan Chiefs and Town / Village Chiefs would be important to consider in this regard. Further, religious leaders such as Pastors and Imams could be motivated to include discourses on water and sanitation in their sermons and religious preaching’s as most religions talk about the importance of cleanliness and hygiene.
12. Working with Food and Water Vendors
Food and water vendors form an important link when it comes to preventing outbreaks of food and water borne diseases such as diarrhoea and cholera. They would need to be oriented on the need to follow hygienic practices in order to prevent outbreaks.
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13. Showcasing Cases of Positive Deviance at the Community Level
In all communities there are cases of ‘Positive Deviance’ – norm changers who defy prescribed or accepted ways of behaving. In this context, these would be families which are practicing recommended water, sanitation and hygiene behaviours. Families which realize that not following these behaviours can seriously affect their health. Such families would be identified and given due recognition and felicitated at the community level. These families would be asked to share their motivational cues as well as coping mechanisms will the community. This would motivate such families as well as other families to adopt positive behaviours.
Segment 2: Communication for creating a positive programme and policy environment The purpose of this segment of the strategy is to mobilize government ministries/ divisions, media, civil society, implementing agencies and other stakeholders to converge and strengthen sanitation programming and policies. Further, it will help to bring focus and attention to the issue. 1. Advocacy While the government and partners have undertaken many measures on water, sanitation and hygiene, it has lacked priority among people. Amongst the general public as well as people’s representatives, other social and economic issues have taken precedence. Therefore, the first step should be to highlight water, sanitation and hygiene at various levels, more prominently among communities, implementers and the policy makers and relevant office bearers. Political support is crucial to establish priority and commitment for the issue and ensure favourable policy. The endorsement by the Government would also help relevant office bearers to prioritize their plan of action. Advocacy will play a key role in ensuring that there is a positive environment in which the water and sanitation programme can be implemented effectively. The primary area for advocacy focus would be on working with partners (like stake holding ministries/ divisions, elected representatives, media, celebrities etc.) who can increase performance, visibility and credibility of the programme. In order to extend the reach and impact of the strategy there should be a focused effort to bring in new partners who can increase visibility and impact. Partnerships can be initiated and be strengthened by making efforts to engage the partners actively in communication interventions. Advocacy at the national, county and district level will play a very crucial role. The thrust of Advocacy will be to establish the context and relevance of the cause. An effective advocacy campaign can also get support from media and can keep the issue alive for a longer period of time in the public domain. A. Advocacy through media Media is poised to play a significant role in improving the status of water, sanitation and hygiene. The media's reach is significant, and the investments made for advocacy through media are cost-effective. Media enjoys a high degree of credibility with the people and can be an effective partner for dissemination of information. Working with the media is also important from the point of view of averting possible negative coverage, which can be counter-productive. Some of the possible activities for media partnership are:
1. Preparation of quality briefing package: The starting point for media advocacy is often a good briefing note which presents the information correctly and with lucidity. The briefing
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note would help in keeping the media community informed about issues around water, sanitation and hygiene.
2. Workshop at the national and county level: In order to sensitize and orient journalists around the issue it would be important to have media workshops at the national as well as in counties. This would help in increasing informed coverage and reporting on the issue.
3. Working with the Ministry of Information, Culture and Tourism: The ministry already has links with the media and is the main source of information dissemination on governmental affairs. Thus they would be an extremely important ally in advocacy related work with the media.
4. Media visits: In order to bridge the gap between theoretical knowledge and ground reality, media exposure to the realities of water, sanitation and hygiene will help in keeping them interested in the programme. The result will be regular media coverage and media monitoring of the programme at the ground level. It is proposed that for each county, two to three media visits are organised every year. It is proposed that partner NGOs are identified for organizing field visits of journalists.
5. Media Fellowships: There are many keen journalists who are willing to take some time off, travel with a purpose, and bring back a rich haul of stories for their newspapers. This can be made possible through media fellowships. Media fellowships will involve the signing of a Memorandum of Understanding between UNICEF and concerned media house. The MoU will specify the nature of grant, the conditions governing it such as how many days the journalist will travel for, which subject or geographic areas he/she will cover and how many stories he/she will come back with. The paper will be committed to publishing at least a certain number of stories. A panel comprising editors, UNICEF and Government will judge applications and award fellowships.
6. Media Awards: A media award announced for a specific subject area leads to a spurt in activity among all media houses. A UNICEF award to journalists for effectively covering water, sanitation and hygiene issues is likely to lead to increased media interest. The awards could be announced in partnership with the Ministry of Health or the Ministry of Information Culture and Tourism. An award function at the national level will be an opportunity to discuss the importance of water, sanitation and hygiene and its connection with child survival and development as well as recognize the work of journalists. A panel comprising UNICEF, Government and Editors will be constituted to judge the awardees, which itself will strengthen the partnership for the water, sanitation and hygiene programme and renew editors' commitment to the programme.
7. Programmes focusing on water, sanitation and hygiene could be supported on radio and television. This will help in bringing the issue in the public domain, generating awareness and action. This would also motivate the political leadership to take the issue up as a priority. Success stories could also be broadcast. News channels can be roped in to do dedicated programming on water, sanitation and hygiene. It could be a series in which each episode or a cluster of episodes deals with water, sanitation and hygiene issues. Regular columns or articles in leading dailies would also be a way of bringing the issue into the limelight.
B. Advocacy through Celebrities Celebrities add great credibility as well as visibility to any programme. Celebrities would be particularly useful for image building and visibility. They could also visit few sites to monitor the activities and this could be covered by the media to raise the profile as well as seriousness of the programme. Considering the immense popularity of football in Liberia, the Liberian football team could be roped in for this purpose.
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C. Advocacy with policy makers Mailers on the issue of water, sanitation and hygiene could be sent to the policy makers and implementers. The mailer would reiterate the context and relevance of the issue in the present scenario. It would also underline specific roles and responsibilities vis-à-vis partners. Screen Savers on water, sanitation and hygiene could also be developed and installed on the computers of political leaders and decision makers in order to buy ‘mindshare’ and assist the process of engaging them in the issue. Workshops with senators and legislators on the issue would also help in generating positive action. D. Advocacy with County / District Administration and relevant authorities responsible for water, sanitation and hygiene Getting a buy-in and partnership with authorities at the county and district level would be crucial in order to ensure proper and smooth implementation of the programme. Developing a joint agreed-upon plan of action with communication related components incorporated would be essential. Thus coordination meetings with County Superintendents, District Commissioners, Health Officers, Environmental Health Officers, WASH coordinators, Community Health Service Directors, Health Promotion/Officers focal points would need to be carried out. F. Advocacy with Partners for Coalition building Partners from all quarters such as INGOs NGOs, community networks, Religious organizations(like the all faith association), and occupational groups etc. would need to be brought into the fold in order to help in the process of mobilization through their networks. They could also be utilized to support county/ district-specific social mobilization activities. Once they have been identified, orientation programmes would need to be carried out for them to clearly lay out specific roles and responsibilities of each. G. Sensitization / Training of County / District Level staff Since at the county and district level, there are no dedicated resources for health promotion, it would be critical to sensitize representatives from stake holding ministries on the importance of water, sanitation and hygiene promotion and their respective roles and responsibilities in relation to the same.
H. Advocacy with Municipal authorities /market owners associations / vendor associations
Solid and liquid waste at markets places attracts breeding of flies and vermin. Municipal authorities/market owners associations/vendors associations need to give priority to maintaining hygienic conditions at market places. Advocacy with these groups through meetings and workshops would be essential to get their commitment around the issue.
2. Setting up / Strengthening Coordination Mechanisms for Health Promotion at National / County
and District Levels
Under the leadership of The Ministry of Health, the Health Promotion division would coordinate the working of a committee on water, sanitation and hygiene promotion, with representation from ministries / departments such as Community Health, Public Works, Land, Mines and Energy, Nutrition, Education, Internal affairs, Information Culture and tourism and development partners. Communication activities would be co-ordinated and implemented through this committee.
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Similar committees would also need to be formed at the county and district levels under the leadership of the county superintendent and district commissioner with support from the county and district health officers and health promotion focal points. These committees should meet at least every quarter to plan, monitor and review progress.
Segment 3: Communication for ensuring community participation and ownership Community participation and ownership is a critical element behind the success of any developmental programme. Unless communities realize the importance of water, sanitation and hygiene and take the management of them into their own hands, the programme will not be successful. Hand pumps may be installed and toilets may be built, but unless the community uses and maintains them they will not sustain. So, more than the hardware, it is important to focus on community attitudes, perceptions, mind sets and motivation. The segment on ensuring participation and ownership would be carried out in sync with the first segment. However, as a prerequisite to this, community animators and workers would have to be trained in carrying out participatory communication activities. 1. Rapport Building with the Community Each community is diverse and different with varying community structures, power dynamics and means of functioning. Before one can begin work with a particular community substantial time and energy must spend in getting acquainted with the community, identifying community leaders/ influencers and power structures that might facilitate or hamper work. Care must be taken to ensure that leaders and / or contact points are truly representative of all sections of the community as communities are rarely, fully homogenous. If leaders/ contact points are not fully representative then, special efforts must be made to include those with a possibility of being left out of the process. Once rapport and trust has been built and leaders identified, work can commence in the community. 2. Participatory Community Needs Assessment Communities need to be involved and engaged in identifying their problems as well as solutions for them. Rarely do solutions given from outside sustain as there is no ownership towards them. Community needs assessment can be done using various participatory methods and techniques such as Transect walks, social mapping, timelines, seasonal calendar, Venn diagrams, focus group discussions, role playing etc. 3. Development of Community Work Plans Once, the problems have been identified, agreed upon and the possible solutions defined, the community would have to develop a work plan to set the work in motion. The work plan would have to clearly identify the key tasks to be performed, timelines, responsibility, external support required and risks. Further, a participatory system of monitoring the progress of the plan would also have to be institutionalized. 4. Capacity building Before people can start acting on the work plan, they might have some capacity building needs. These would have to be identified by the facilitators and addressed.
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5. Formation of a Community Level Committee on Water, Sanitation and Hygiene In order to oversee and manage the implementation of the plan, a committee comprising of community leaders and representatives from all sections of the community would have to be formed. The Community Health Development committees could also be used in this regard. 6. Ensuring Community Participation in the rollout The committee would have to ensure that people contribute to the rollout of the plan through financial/ material /human resources, however small it may be. The initiative might be supported by an external agency, but contribution from the community for the execution of the plan would be vital. Further, once water sources/ latrines etc. have been constructed, the committee would have to also ensure the participation of people in their maintenance. 7. Creating new social norms The committee would also need to implement certain checks and balances to ensure that people do not revert back to their old behaviour and are engaged in the programme. Social sanctions against people not following the recommended practices such as defecating in the open, not participating in the maintenance of community toilets, etc. would have to be implemented. Children’s groups could play a key role in this regard, by acting as ‘eyes and ears’ of the committee and /or community leadership. 8. Engaging Women Women are often the biggest sufferers when it comes to issues of inadequate water and sanitation facilities. Further, they are the ones who are involved in ensuring availability of water and maintaining hygiene in their families. Experience world over has shown that projects that focus on involving women have greater chances of success. Thus going by the fact, that the perceived need among women and their motivation is higher, community projects would have to ensure that women are provided significant roles in them.
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Annexure 4: Preparedness & Response for Cholera – Phases
Preparedness Phase 1. Enhancing Coordination through the Sub Committee on Health Promotion Effective prevention, preparedness and response for cholera require co-ordination and communication across sectors and at all levels. The following figure highlights the potential impact of a rapid public health response, including co-ordination and pro-active communication, to reduce the size and scale of an outbreak. The purpose of co-ordination would be to:
Ensure coherence of the prevention, preparedness or response activities through the development of plans and agreement on approaches, channels, messages and materials.
Avoid gaps and duplication
Make the most effective use of partners and resources
Undertake collaborative assessments
Effectively share information
Build capacities
Mobilise resources
Instigate timely monitoring and reporting
Develop a common, agreed upon plan of action Ideally, co-ordination for communication preparedness activities should be included as part of long-term structures in water, sanitation and hygiene. Under the leadership of The Ministry of Health, the Health Promotion division would coordinate the working of the sub- committee on health promotion, with representation from ministries / departments such as Community Health, Public Works, Land, Mines and Energy, Nutrition, Education, Internal affairs, Information Culture and Tourism and development partners. It is recommended that the same committee that is created for
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Water, Sanitation and Hygiene promotion be used for Cholera preparedness and response as well so that it can be integrated into the larger initiatives around Water, Sanitation and Hygiene promotion. Similar committees would also need to be formed at the county and district levels under the leadership of the county superintendent and district commissioner with support from the county and district health officers and health promotion focal points. These committees should meet at least every quarter to plan, monitor and review progress. 2. Development of a communication plan The development of an inter-sectoral communication plan is the first step in ensuring effective communication. The communication plan would define the objectives, the approaches, the resources required including human resources, the participant groups and the means to ensure dialogue /deliver the messages. The plan defines the specific actions to be taken to reach the goal according to the strategy. It aims to:
Provide useful, consistent and timely information to participant groups on measures to be taken to protect themselves and access services as and when required
Mobilize key stakeholders including government departments, civil society, media and affected communities to contribute to addressing the outbreak.
Provide timely information to people, media and key stakeholders on the course of the outbreak and the measures being taken to address it.
Provide a platform for transparent feedback and suggestions from affected communities with regard to the effectiveness of cholera interventions.
3. Co-ordination across borders Liberia shares a long border with Sierra Leone, Guinea and Côte d’Ivoire. These countries have a history of cholera outbreaks. Hence co-ordination will be required between government authorities at national and local government levels with these countries to prevent the spread of Cholera across borders. The main linkages are likely to be between the ministries and authorities responsible for health. Coordination may be undertaken to develop joint surveillance and early warning plans and communication channels and procedures. 4. Investing in communication research Designing a communication plan should begin with a formative study and assessment of the context in which cholera occurs including the people involved, those who produce the information, those who disseminate it and those who receive it, resources available and any barriers to implementation. The study identifies the knowledge, attitudes, perceptions, beliefs and practices of the people involved on the issue and helps to identify the different means for bringing about change. A more detailed assessment of specific hygiene practices, motivations and beliefs in relation to cholera will also be required and ideally should be carried out before a cholera outbreak. However on-going assessment, monitoring and listening to communities will also be vital during the outbreak. The assessment should try to identify the:
Key practices that are putting people at risk of cholera
Alternative or safer practices that would help to mitigate cholera
Barriers that prevent people from adopting safer practices
Key motivating factors that will enable change
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Preferred communication channels for different participant groups
Particularly vulnerable or high risk groups The assessment process involves working with and listening closely to the different participant groups. Focus group discussions and interviews with key informants are the key assessment methods for understanding what is happening in the affected population. Such ‘qualitative’ methods also aim to understand why something is happening and what can be done about it. It may also be useful to undertake a simple household questionnaire survey to obtain some ‘quantitative’ data on the coverage of specific practices in order to monitor the effectiveness of communication efforts. Even where an in-depth assessment has been carried out before the outbreak, it will still be necessary to identify a specific team to conduct a rapid assessment in the early stages of a large epidemic to review what is known and to amend the draft communication strategy and plans. Preparing a monitoring and evaluation (M&E) plan would be important as well. M&E enables to track progress and impact at given periods of the emergency response in terms of message and channel reach, resource use and most of, all in terms of desired results. 5. Identifying communication channels It is advisable to use both interpersonal methods and mass media methods during a cholera outbreak. The mass media (e.g. radio, television, text messaging via mobile phones) helps quickly inform large numbers of people but they often do not provide the opportunity for feedback. Working with communities through a process of dialogue, can help identify the barriers to change and specific cultural and social beliefs and practices which might act as impediments. Sustained dialogue can help bring about community involvement and participation in addressing the outbreak. 6. Standardization of messages, preparing action oriented communication materials and keeping them ready for dissemination Sample messages and materials that have been pre-tested would have to be developed, produced and prepositioned in advance. These would have to be stocked at the county/ district level, so that during an outbreak they can be immediately distributed in the field. This will save precious time and resources. In the eventuality that new materials need to be produced and disseminated, it would also be helpful to create a database of graphic designers, media producers, radio /TV Channel contacts etc. for emergency support.
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A. Developing messages One-way messages, alone, may not be effective in bringing about behaviour change. However, all those involved in cholera prevention and response should be providing consistent information to the participant groups in order to avoid confusion and misunderstandings. Different agencies need to coordinate so that there is consistency in the messages that are reaching communities. Agencies need to come together and draft a common set of messages before developing any communication materials. It might also be helpful to decide which partner is going to develop which kind of materials in order to avoid duplication of efforts and promote sharing. B. Developing audio visual aids Materials such as banners, leaflets, posters, flipcharts, flashcards, films and interactive materials such as games and activities can be very useful for health workers, community workers or volunteers in carrying out effective dialogue with families and communities. The materials also help in reducing ‘transmission loss’ while communicating with people as they also serve as reference for the communicator. Audio-visual aids such as TV and Radio spots are also useful in reaching out to large number of people. However, aids need to be rigorously pretested to ensure that they are communicating what was intended to be communicated. Sometimes, instead of reinventing the wheel, it might be helpful also to review existing materials and adapt/modify them as required. Further, communications materials must be seen as one of the means towards reaching the end and not something that can guarantee change on their own. 7. Training service providers / community level workers in interpersonal communication skills In times of stress and trauma caused by an outbreak, health workers and specially community level communicators such as Animators, GCHVs, HHP etc. need to possess and maintain good interpersonal communication skills to inform, motivate, counsel and encourage affected people and communities. They would also need to know how to deal with the distress and anxiety experienced by people who come for assistance as well as among themselves. Thus training them on interpersonal communication would be an important preparatory activity. This could be combined with the suggested interpersonal communication skills training for general water, sanitation and hygiene promotion. 8. Engaging communities in preparing and planning for emergencies The human rights-based approach stresses on participatory approaches that engage communities in planning, implementation and monitoring processes. This means that programs should build on what people already know and that their social and cultural strengths are recognized. However, communities are not homogeneous. Vulnerabilities related to age, gender inequalities, ethnicity, caste, socio-economic status and disability, are factors that may affect people's ability to take part in decision-making processes. Supporting communities in areas particularly vulnerable to cholera, to develop community action plans themselves is a key preparedness activity. The Community Health Development Committees (CHDCs) could be instrumental in developing and supervising the implementation of the plan. Community action plans could detail:
Specific actions to improve water, sanitation and hygiene practices of different groups in the community (e.g. Tippy – Tap’s).
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How to make sure that all community members know what to do if someone in their family or neighbourhood gets cholera.
How to support people in seeking services
Where an ORS corner could be located and who would manage it in the event of an outbreak.
What precautions would be taken at mass gatherings such as funerals and weddings?
What improvements could be made to markets or public institutions such as schools?
Who is available to help and what communication will be necessary in the event of an outbreak e.g. with authorities, health personnel etc.
9. Testing the communication plan by mock drills and exercises Even very well developed communication plans for emergencies may fail during actual implementation. Therefore it is necessary to conduct a ‘reality check’ before the ‘rubber hits the road’. Communication plans need to be pre-tested through mock –drills to ensure that they work well during emergencies.
Response Phase 1. Developing a communication protocol and partnerships for collaboration When an emergency strikes, it is likely that there would be a great deal of anxiety, confusion an information emerging from multiple sources. This would be expounded if there is weak coordination among different partners serving communities. A plan would need to be developed with key partners which outlines how communication efforts will be coordinated, with clearly defined roles and responsibilities. Agreement on how information will be managed should be clear. This should also help to prevent and manage rumours, misinformation and unwanted results that often happen during outbreaks. The subcommittee on health promotion for cholera should meet frequently (at least weekly) during the outbreak period. During the peak of an outbreak, the task forces or committees managing the direct responses, such as at the county and district level, will need to meet daily to discuss the progression of the cholera, progress in the response and gaps and to prioritise actions. 2. Participation in sectoral rapid assessments When health, water and sanitation assessments are conducted in the initial phase of an emergency, it is critical that the assessments also identify any high risk practices that have implications for communication among affected caregivers and communities. This information is critical to map out the detailed communication responses. Further, a clear understanding of the geographical areas that need priority intervention is essential as it will help focus and target communication initiatives. 3. Conducting a rapid appraisal of communication channels and resources Soon after an outbreak is announced, efforts would need to be made to find ways to reach the vast majority of affected people quickly with information and key messages. Hence, Assessing the availability and reach of media and other communication channels would need to be carried out (in many ways, it might be a validation of the channels identified in the preparedness plan). Along with mass media approaches, low cost and low-tech communications systems might be the most practical and effective during such difficult circumstances. Megaphones, car battery-operated public address systems, community radio (also powered by battery or generators) would be good ways to quickly disseminate messages to affected families and communities. Public gatherings and community or
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camp meetings would provide further opportunities to quickly share information. Choosing more than one communication channel to help reinforce the information would be important. Beyond using mass and small media, interpersonal and participatory community based media are very useful channels to lead communication efforts. To choose the right mix of channels in the different phases of an emergency response, the following need to be considered:
How do affected families and communities get and share information?
Who are seen as trusted and credible sources of information in the community?
Which groups have access to mass media and other sources of information and which groups do not?
What traditional and local means of communication are available? 4. Revisiting and activating the detailed communication plan Based on the preparedness plan, the details of the implementation of the communication initiative(s) would have to be established. This would include activities related to:
Activating coordination with stake holding divisions/ ministries and partners at national, county and district levels
Engaging with the media
Developing a media plan for mass media initiatives and a dissemination plan for print and AV materials
Refresher/ orientation of community workers as required
Deployment of animators in affected areas
Activating community level structures for community mobilization activities- community meetings, household visits, drama shows, film shows, megaphone narrowcasts, demonstrations, communication material distribution
Developing a monitoring and evaluation plan 5. Focusing on re-establishing existing behaviors and norms In the initial outbreak phase, the focus would be on re-establishing positive behaviors that existed prior to the outbreak. Focus would not only be on individual behaviors and actions, but seeking to re-establish positive social and cultural values that might exist. However, depending on the situation, emergencies might also provide opportunities to promote new behaviors. 6. Forging additional alliances for communication The outbreak might provide opportunities to build additional alliances to include relief workers, service providers, journalists and others so that they are able to support directly desired behaviors of affected people. Committees at all levels would have to actively search for such potential alliances 7. Facilitating community and children's participation Through already established community level committees and structures, pro-active efforts would need to be made in creating opportunities for affected families and communities, including children and young people, to participate in the response. Particular care would have to be taken to include especially vulnerable groups, whether this requires inviting representatives from children and young people's organizations, women representatives, religious leaders, asking vulnerable populations to
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nominate spokespersons or advocating with community and local authorities to consult affected communities. 8. Working with the media Establishing a good working relationship with the media and with the Ministry of Information, Cultural affairs and Tourism before the outbreak will be of great importance as timely dissemination of information to communities during an outbreak is of the essence in order to control the outbreak. Along with being timely, the information also needs to be accurate as news of an outbreak can lead to a lot of tension and anxiety among people. Thus, as a priority, decision makers should come together and decide on what to communicate to the media. The communication would need to be frequent and effective. Although the media might sometimes end up distorting or misrepresenting facts, this more often than not happens due to lack of clear communication with them. Once, a good working relationship has been established with them, they can be a very good and powerful ally. The first step in ensuring a constructive relationship with the media is to have a designated, skilled spokesperson who can represent the situation on behalf of the government and partners in relation to cholera. Authority would need to be delegated to this person for holding regular media conferences and issuing press releases. Many countries have a public service requirement for radio / TV stations, through which the government can channel announcements at no cost. For example, in Tanzania the government regularly announces outbreak news during a regular weekly slot on one radio station. Key information on how to prevent cholera and where to go for treatment should be broadcasted, as well as information on the status of the outbreak and what different stakeholders are doing. 9. Listening through Dialogue and Tackling rumors During an outbreak, it would be crucial to set up a rumor tracking system to identify, investigate and address misperceptions or misunderstandings. This could be done by developing a feedback mechanism through GCHVs and community level service providers, who on a periodic basis could report back on issues in the community. This would need to be incorporated into the regular monitoring system. Further, a strong relation with the media would also be very important to deal with rumors. 10. Reaching the poorest and those in particularly vulnerable, hard to reach or special circumstances – Equity perspective Particular attention should be paid to people who are more vulnerable or marginalised in a given context or those who are harder to reach through special outreach activities. People who are vulnerable, harder to reach or living in special circumstances, may be living in extreme poverty, may be malnourished, may have a long-term condition such as HIV/AIDS or may live on the streets. They may also be living in child, elderly or female headed households, or have limited mobility. 11. Dealing with psychosocial impact Cholera can have a variety of psychosocial impacts. People may have strong feelings of fear and insecurity and helplessness during an outbreak; they may be stigmatised if they seek treatment or suffer from severe diarrhoea; their suffering might be expounded by the fact that they might not be allowed to undertake usual funeral and mourning practices. The supportive attitude of medical
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/nursing staff and community workers is essential in helping to reduce the stigma associated with cholera. Thus, they must be sensitised on this issue. Further, as part of the communication activities, efforts will have to be made for having non-judgemental discussions around cholera and involving community leaders to help reduce stigma in the community.
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Annexure 5: Communication Matrix: Current Views, Themes to Address, Communication Methods and Inputs
Communication Objective1: Increase in the percentage of families and communities that practice safer water, sanitation and hygiene behaviors by end 2015 Primary Participant Group: Children
Sl.No. Current View Themes to Address Communication Methods
Inputs
1. It is okay to eat fruits vegetables without washing them
Unwashed fruits and vegetables have many germs which cannot be seen by the naked eye and could make you fall very sick
Special classroom activities in schools by teachers Peer Counsellors/ Buddy pairs School Health Clubs Clubs for out of school children Community Drama Radio /TV spots and programmes Messaging through football-based programmes
Teacher training Formation of peer counsellors and buddy pairs Formation of school health clubs Formation of clubs for out of school children Development of a ‘school hygiene promotion kit’ Orientation of community drama
2. Food that has fallen on the ground can be dusted to remove the dirt on it and then eaten
When food falls on the ground, it comes in contact with germs that cannot be seen. These can make you very sick. Hence it should not be eaten.
3. Eating food from street venders is not a problem
Before eating anything from street venders ensure that the food is warm, is covered so that files cannot sit on it and not being handled directly by hands
4. Water from an open well or creek is safe to drink directly
Germs in the water can make you very sick. Water needs to be purified by chlorination or boiling till a roll before drinking
5. Having drinking water / ice creams from street vendors is okay
Having drinking water/ ice cream from street vendors is not safe as there is no way to check the quality of water they are using
6.. It is okay to defecate wherever it is convenient. Such as in plastic bags, near creeks/springs/ beach/river
It is critical to dispose faeces safely in a toilet as human faeces (including children’s) are very harmful: One gram of faeces contains 10,000,000 viruses, 1,000,000 bacteria and 1,000 parasite cysts. If these enter our body, they can make us very sick.
7. After defecating, there is no Human faeces (including children’s) have a lot of germs. These are
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need to wash hands or it is okay to just wash hands with water
not destroyed by plain water. Soap has certain special properties which can kill these germs and protect us from getting sick. Hence it is essential to always wash our hands with soap after defecating.
groups Development and airing of Radio/TV spots and programmes Organising football –based programmes for children
8 There is no need to wash hands with soap before eating/ touching food or it is okay to just wash with water
Our hands are always touching something or the other and in the process, pick up harmful germs. Soap has certain special properties which can kill these germs and protect us from getting sick. Hence it is essential to always wash our hands with soap before eating. Remember otherwise along with the food, harmful germs are also entering your body.
9. Hands that look clean are clean. There is no need to wash hands unless they appear dirty.
Since our hands are always touching something or the other, which have germs on them, Our hands pick up these invisible germs which can make us sick. Hence hands which might appear clean are not and can make us and others sick if we do not clean them with soap.
10. Lack of knowledge about how to effectively wash hands
Wash your hands with soap under the faucet or ask someone to pour water over your hands
Wet your hands thoroughly and then soap them
Scrub your nails, your fingertips, your palms and the back of your hands
Rinse them thoroughly
Shake them until dry
11. Garbage can be thrown outside the house or into drains
Garbage that lies around breeds a lot of germs. These can reach us through files and by contaminating our water sources. Rubbish should be kept in bins and burnt at a site far from the house
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Primary Participant Group: Men / Women /Parents (With a focus on Mothers)
The analysis for children would apply to men/women/ parents as well. In addition, there are a few more views and themes for this group
Sl.No. Current View Themes to Address Communication Methods Inputs
1. It is okay to eat certain foods raw or without cooking thoroughly
All food needs to be washed and cooked thoroughly before eating specially leafy vegetables, fish, crab, shrimp etc. as otherwise the germs in them could still remain and cause serious illnesses.
IPC by GCHVs, HHPs, TTMs and Animators Community Drama Radio /TV spots and programmes Messages through beauty parlours/ salons / barbers Messaging through gospel singers and popular musicians SMSs/voice messages through mobile phones Wall paintings/hoardings Film shows and discussion at video clubs Messaging through town criers Communication through Nurse, Physician Attendants, Environmental Health
IPC skills training for GCHVs, HHPs, TTMs and animators Orientation of community drama groups Development and airing of Radio/TV spots and programmes Orientation of beauty parlours/ salons / barbers Working with gospel singers and popular musicians to develop songs Working with cell phone companies to develop and disseminate messages Development and execution of wall
2. It is not necessary to keep food covered
Not keeping food covered can cause dust to fall on it or even flies to sit on it. Flies carry a lot of disease causing germs. You never know, they might have been sitting on faeces before sitting on your food!
3. Cooked food can be eaten cold as long as it doesn’t taste bad
Cooked food should always be eaten warm as germs build up on food that is lying cold.
4. Water from water vendors is safe to drink directly
There is no way to ensure that the water from vendors is fully safe. Therefore we should always add a cleaning agent such as Aquatab to it before drinking
5. There is no need to clean water storage containers/ it is okay to wash it with just water. Further, there might not be a need to cover it
Every time you change the water, wash the container with soapy water as germs can build up in stagnant water too. Always keep you drinking water covered (or lid closed in the case of buckets/jerry cans)
6. Children’s faeces are not harmful and can be disposed off anywhere
It is critical to dispose faeces safely in a toilet as human faeces (including children’s) are very harmful: One gram of faeces contains 10,000,000 viruses, 1,000,000 bacteria and 1,000 parasite cysts. If these enter our body, they can make us very sick. In fact children’s faeces have more viruses, germs and bacteria than an adult’s faeces.
7. There is no need to frequently wash hand with
Our hands are always touching something or the other and in the process, pick up harmful germs. Soap has
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soap and water certain special properties which can kill these germs and protect us from getting sick. Hence it is essential to always wash our hands with soap:
Before eating/ touching preparing food
Before feeding children
Touching and taking care of infants
After touching a sick person suffering from diarrhoea/ vomiting
After coming back from outside the house
After touching something touched my others such as money, phone
After cleaning a child’s bottom after he /she has passed stools
Technicians and Doctors Motivation by religious leaders/ community leaders Peer counselling by women groups Showcasing cases of positive deviance at community level Messaging through football-based programmes
paintings and hoardings Development of a film on WASH and screening at video clubs through agreements Development of messages for town criers and providing them to town chiefs for dissemination Orientation of health care providers Orientation of religious and community leaders Formation of women’s community groups Identifying cases of positive deviance and showcasing them at community meetings Organising football –based programmes
8. It is not essential to wash breasts with soap and water before breastfeeding
It is vital to wash breasts with soap and water (especially the area around the nipples) as it may contain germs which would then enter the child’s body and make him or her sick.
9. It is okay to give water to a child below six months of age
A child below six months needs nothing other than breast milk. Breast milk fulfils all the needs of the child including water. Giving anything might make the child fall sick. Further, for children above six months of age, breastfeeding should be continued along with food that is prepared hygienically.
10. Utensils can be cleaned by washing them with water
Soap has certain special properties which can kill germs and protect us from getting sick. Therefore utensils should always be washed using soap. Further, they should be kept in a rack above the ground so that they do not get dirty again.
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Primary Participant Group: Food and Water Vendors As members of the community, they would also need to be sensitized using the same themes as parents and children. However, there are some special themes for them, linked to their occupation
Sl.No. Current View Themes to Address Communication methods Inputs
1. As a Food and Fruit vendor , not sure about role in prevention of diseases
You have a key role to play in maintaining the good health of your customer. If your customers fall sick, who will you sell to and make a living? You can protect the health of your customers by following a few simple things:
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
5. Keep a 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 only unpeeled or unsliced fruits
10. Always keep your food /fruits covered so that flies cannot sit on them
11. Tell your customers what you know about preventing diseases!
Orientation on maintaining proper hygiene IPC by GCHVs, HHPs, TTMs and Animators Community Drama Radio /TV spots and programmes Messaging through gospel singers and popular musicians SMSs/voice messages through mobile phones Wall paintings/hoardings Film shows and discussion at video clubs Motivation by religious leaders/ community leaders
Organizing orientation for food and water vendors IPC skills training for GCHVs, HHPs, TTMs and animators Orientation of community drama groups Development and airing of Radio/TV spots and programmes Working with gospel singers and popular musicians to develop songs Working with cell phone companies to develop and disseminate messages Development and execution of wall paintings and hoardings Development of a film on WASH and screening at
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2. As a water vendor , not sure about role in prevention of diseases
You have a key role to play in maintaining the good health of your customer. If your customers fall sick, who will you sell to and make a living? You can protect the health of your customers by following a few simple things:
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/ jerry cans 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. Advise your customers to boil all water or treat it with chlorine as any water can be contaminated, even if it looks clean
7. Tell your customers what you know about preventing diseases!
video clubs through agreements Orientation of religious and community leaders
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Communication Objective 2: Increase in the collaboration between various stake holding government ministries/ departments, development partners, media and civil society organizations at all levels to advocate for as well as address issues related to water, sanitation and hygiene by end 2015
Tertiary Participants: Representatives / Functionaries of various stake holding government ministries/ departments, development partners, media and
civil society organizations
Sl.No. Current Situation Themes to Address Communication methods
Inputs
1. Each ministry/department is working within its own orbit of influence
Various stake-holding ministries/ departments such as Public Works, Land, Mines and Energy, Environmental Health, Health, Nutrition, Education, Internal affairs, Information Culture and Tourism and development partners need to come together through a ‘Task force’ on Water, Sanitation and hygiene as positive outcomes in these areas will have an impact on all the other sectors
Within the ministry of Health, instead of having ‘Focal persons’ for health promotion, it would be crucial to have dedicated resources for it at county , district and community level. This finds mention in the National Health and Social Welfare Policy for 2011-2012
Each county and district should incorporate a component of sanitation and hygiene promotion in their plans and allocate resources for the same
Specific guidelines and communication materials and tools should be developed by the Health Promotion Division and sent to the counties and districts specially for the GCHVs and HHPs
Advocacy meetings & workshops Setting up coordination mechanisms at national/county and district level
Development of advocacy notes Carrying out meetings and workshops
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The Health Promotion division should be involved in the planning process of other departments / ministries that it closely works with so that communication plans and budgets can be incorporated into the plans of each of the departments/ ministries
Development partners/ civil society organisations should concertedly support and advocate for convergent planning and implementation.
At the county and district level special initiatives should be taken for promoting community management of water, sanitation and hygiene projects. Communities would also have to provided with need-based and timely response and support.
2. Issues of WASH, AWD, Cholera are not a priority for the media
Water, Sanitation and Hygiene are critical in ensuring the health of the nation. The media has a critical role to play in highlighting the status of these issues so that people consider it to be a priority and also governmental/ policy action is ensured.
The media including the association of community radio operators should take the issue up as an issue of national concern and bring it into the limelight through dedicated programming and coverage.
Key facts about WASH, cholera prevention and control addressing myths, beliefs and practices
Signs and symptoms
Mode of transmission
Prevention and control measures (hand-washing with soap, latrine use, food hygiene, personal hygiene etc.)
Treatment centres
Use of home based care (ORS) and fluids
Where to get information – Outbreaks alert / Early Warning – the MOHSW reports on outbreaks
Media Workshops Media visits Media fellowships Media Awards
Development of a media-briefing kit Organising workshops/ fellowships and awards
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3. Celebrities like football stars – Liberian football team – Lone Star
Motivating them to support the cause Advocacy meetings to mobilize their support
Working with the team to get them on board Carrying out mobilisation activities and development / dissemination of communication materials
Communication Objective 3: Increase in the number communities actively participating in the management of water, sanitation and hygiene in their areas by end 2015 Primary Participants: Children
Sl.No. Current View Themes to Address Communication Methods
Inputs
1. As children, we do not know much/ cannot do much in relation to water, sanitation and hygiene
You are the future. You have the capacity to bring about change for yourself and your communities. You can:
Learn more about how you can protect yourself and your community from illnesses and disease by adopting safer practices
Practice these yourself and tell your peers
Form groups among yourselves and talk to people about the need to adopt safer practices
Carry out ‘special drives’ to clean your community, promote hand washing and use of toilets
Your community people might end up considering you to be really ‘cool’ and ‘smart’. You never know. When you grow up, they might even consider making you their leader!
Special classroom activities in schools by teachers Peer Counsellors/ Buddy pairs School Health Clubs Clubs for out of school children Community Drama Messaging through football-based
Teacher training Formation of peer counsellors and buddy pairs Formation of school health clubs Formation of clubs for out of school children Development of a ‘school hygiene promotion kit’
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programmes
Orientation of community drama groups Organising football –based programmes for children
Primary Participants: Men / Fathers
Sl.No. Current View Themes to Address Communication methods Inputs
1. What can we do in relation to water, sanitation and hygiene? It is the responsibility of the government / NGOs
The Government/ NGOs are there to help you / facilitate the process of you achieving good health. But the ultimate responsibility lies with you. A few simple actions can ensure good health for you, your families and the community. You could:
Learn more about how you can protect yourself and your community from illnesses and disease by adopting safer practices
Form a community group to assess the problems facing your community and draw up plans to address them
Come together to build/ maintain toilets
Establish safe drinking water sources for your community
Motivate others in the community to use these and adopt hygienic practices
Doing these will not take away much from your daily schedules. This is as important a part of your
Through participatory techniques, involving men in the needs, assessment, planning, implementation and monitoring of WASH in their communities
Training of animators for carrying out participatory communication.
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life as anything else. It will just ensure that you lead a better life in a better community.
Primary Participants: Women (With a focus on Mothers)
Sl.No. Current View Themes to Address Communication methods Inputs
1. We as women/ mothers already have a lot of work we do not have the time to look at issues of water, sanitation and hygiene.
As a woman/ mother you are concerned about your family and already doing a lot. You do not have to do anything extra. It is just about doing things a bit differently so that you can ensure better health and a better life for yourself, your family and the community. You can:
Learn more about how you can protect yourself and your community from illnesses and disease by adopting safer practices
Try out these simple things and before you know, they will become a new habit and you won’t even realize that you are doing something new!
Talk to your friends about it, form a group, meet once in a while, share your experiences and tell others. It might be a good excuse for you to catch up with your friends over some gossip too!
Through participatory techniques, involving women in the needs, assessment, planning, implementation and monitoring of WASH in their communities Peer education through women’s groups
Training of animators for carrying out participatory communication Formation and training of women’s groups
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Primary Participants: Food and Water Vendors
Sl.No. Current View Themes to Address Communication methods
Inputs
1. As a vendor I am too busy doing my own job. What can I do in this regard?
You have a key role to play in maintaining the good health of your customer. If your customers fall sick, who will you sell to and make a living? You can protect the health of your customers by following a few simple hygiene practices.
As it is, you know most of your customers and maybe even chat with them!
Tell them what you know an maybe even slip them a leaflet with a few messages( will need to be provided to them)
Orientation on maintaining proper hygiene
Organizing orientation for food and water vendors
Secondary Participants: Video club / parlor/ salon owners/ barbers
Sl.No. Current View Themes to Address Communication methods
Inputs
1. Not sure about role in promoting water/sanitation and hygiene
You have a key role to play in maintaining the good health of your customer. If your customers fall sick, who will make a living out of?
Learn more about how you can protect yourself and your customers from illnesses and disease by adopting safer practices
Screen films at your video club on the issue and talk to your customers about it ( films would have to be provided to them)
Your customers trust you with their hair, so they would trust you with what you tell them! Talk to them while cutting hair, put up a few posters, use them to explain, hand them a leaflet with messages as they leave ( materials will need to be provided)
Orientation of beauty parlours/ salons / barbers
Organizing orientation of beauty parlours/ salons / barbers
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Secondary Participants: Teachers
Sl.No. Current View Themes to Address Communication methods
Inputs
1. Role is to teach children but not sure about role in promoting water/sanitation and hygiene
As you know, the overall wellbeing of children is your interest and not just their education. You are doing a great job by providing them education, but to ensure that they can remain healthy to study well, you need to :
Ensure that the school has well-functioning toilets and safe sources for drinking water
Children wash their hands with soap after defection and before eating food
Carry out sessions on hygiene education
Form groups of children to monitor hygiene among peers
Motivate children to talk to their parents and community members on the issue
As a respected member of the community, motivate people to take responsibility for hygiene and sanitation initiatives in the community.
Orientation of teachers
Organizing orientation of teachers
Secondary Participants: GCHVs, TTMs, HHPs, EHTs, PAs, Nurses, Doctors
Sl.No. Current View Themes to Address Communication methods
Inputs
1. Each have their own responsibilities beyond sanitation and hygiene promotion
Proper sanitation and hygiene practices are the most essential part of ensuring good health of the communities you diligently serve. Hence it is crucial to motivate people to practice them.
The focus would have to be to buy their ‘mindshare’ towards responsibilities related to sanitation and hygiene promotion specially for GCHVs, HHPs TTMs and EHTs
Sensitization of service providers
Organizing sensitization of service providers
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Secondary Participants: Community leaders, Religious Leaders, Paramount chiefs/ Clan chiefs
Sl.No. Current View Themes to Address Communication methods
Inputs
1. Water, Sanitation and Hygiene is not a priority. People have other, more pressing issues to deal with such as livelihoods
Learn more about how you can protect yourself and your communities from illnesses and disease by adopting safer practices
Water, Sanitation and hygiene are the critical building blocks for a healthy community. People who keep falling sick will not be healthy and happy. Further, it would make them poorer as they will not be able to work and spend their money on treatment and medicines.
You have the power to bring about change. People in your communities respect you and will listen to you.
Motivate people to follow positive practices
Conduct meetings in your communities to sensitize people on the need to adopt positive practices
Include sanitation and hygiene in your religious sermons and discourses
Set up community norms against open defection and drinking of unsafe water
Liase with government representatives, legislators and NGOs to ensure that facilities are provided in your communities
Form groups/ committees in your communities to maintain toilets and water sources
Orientation of community and religious leaders
Organizing orientation of community and religious leaders
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Secondary Participants: Trader’s Associations
Sl.No. Current View Themes to Address Communication methods
Inputs
1. Role in this regard is unclear
You have a key role to play in maintaining the good health of your customers. If your customers fall sick, who will your association members sell to and make a living? You can protect the health of your customers by following a few simple hygiene practices.
Ensure that vendors who are part of your association maintain prescribed hygiene standards
Carry out spot checks to ensure compliance
Advocacy meetings with trader’s associations
Conducting advocacy meetings.
Secondary Participants: Community toilet operators
Sl.No. Current View Themes to Address Communication methods
Inputs
1. Our role is to maintain the toilets. Beyond that, our role is unclear
You are carrying out a very commendable job by ensuring that people in your community have the opportunity to practice a safe behaviour. However, you need to motivate others who are not
More people coming to your toilet would also mean more business for you!
Orientation of community toilet operators
Organizing orientation of toilet operators
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Communication Objective 4: Increase in the percentage of families and communities who practice recommended water, sanitation, hygiene and treatment seeking practices during AWD and Cholera outbreaks by end 2015
Primary Participants: Children
Sl.No. Current View Themes to Address Communication methods
Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions
Cholera is spreading by eating contaminated food or water / made dirty by the cholera germ – everyone is at risk. Normally the disease is spread by not observing good sanitation and hygiene. Anyone with acute, watery diarrhoea needs to go to a health centre straight away for treatment
1. If you see a fellow pupil vomiting and with 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 a toilet when you are at school and at home. Toilets should be kept clean, to prevent spread of 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 not eat fruits that are not washed well
7. Don’t touch vomit. Pour chlorine over it to prevent the spread of
Special classroom activities in schools by teachers Peer Counsellors/ Buddy pairs School Health Clubs Clubs for out of school children Community Drama Radio /TV spots and programmes Messaging through football-based programmes
Teacher training Formation of peer counsellors and buddy pairs Formation of school health clubs Formation of clubs for out of school children Development of a ‘school hygiene promotion kit’ Orientation of community drama groups Development and
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bacteria, take the patient to a treatment centre while giving him/her ORS (or mixture of sugar and salt) or safe water on the way.
8. You must inform a teacher / your parents as soon as possible
airing of Radio/TV spots and programmes Organising football –based programmes
Primary Participants: Men / Fathers
Sl.No. Current View Themes to Address Communication Methods Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions
Cholera is spreading by eating contaminated food or water / made dirty by the cholera germ – everyone is at risk. Normally the disease is spread by not observing good sanitation and hygiene. Anyone with acute, watery diarrhoea needs to go to a health centre straight away for treatment
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)
o Do not drink local brew during the cholera outbreak
o Do not hide a patient with cholera symptoms – take him/her immediately to the treatment centre
Your protection 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)
IPC by GCHVs, HHPs, TTMs and Animators Community Drama Radio /TV spots and programmes Messages through beauty parlours/ salons / barbers Messaging through gospel singers and popular musicians SMSs/voice messages through mobile phones Wall paintings/hoardings Film shows and discussion at video clubs
IPC skills training for GCHVs, HHPs, TTMs and animators Orientation of community drama groups Development and airing of Radio/TV spots and programmes Orientation of beauty parlours/ salons / barbers Working with gospel singers and popular musicians to develop songs Working with cell
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4. Before eating and feeding a child 5. Before preparing/cooking food
Gatherings are contributing to the spread of cholera:
1. Avoid gatherings during the cholera outbreak 2. Do not eat or drink at any gatherings e.g. at funerals or
celebrations, weddings, open markets etc. during the cholera outbreak
3. The bodies of people who have died of cholera are very infectious. Take help from professionals who arrange funerals
4. Where possible, do not provide food at funerals. If provided, people who prepare the body must not prepare the food
5. Everyone at a funeral during a cholera outbreak must wash their hands:
o After going to the latrine o After touching the body if it is an important
custom o Before eating food or drinking
Messaging through town criers Communication through Nurse, Physician Attendants, Environmental Health Technicians and Doctors Motivation by religious leaders/ community leaders Peer counselling by women groups Messaging through football-based programmes
phone companies to develop and disseminate messages Development and execution of wall paintings and hoardings Development of a film on WASH and screening at video clubs through agreements Development of messages for town criers and providing them to town chiefs for dissemination Orientation of health care providers Orientation of religious and community leaders Formation of women’s community groups Organising football –based programmes
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Primary Participants: Women/ Mothers
In addition to the themes for Men, these would also apply:
Sl.No. Current View Themes to Address Communication Methods Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions
Things to do if you or your child, you or anyone in the family has diarrhoea and /or 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 or other fluids (except fizzy drinks)
3. Wash your hands with soap and water before preparing the mixture.
4. Put the contents of the ORS packet in a clean covered container. Add one litre of clean water and stir. Too little water could make the diarrhoea worse.
5. Add water only. Do not add ORS to milk, soup, fruit juice or soft drinks. Do not add sugar.
6. Stir well, and drink it/feed it to the child from a clean cup. Do not use a bottle. Give one glass after each episode of diarrhoea.
7. You can use this mixture for up to 24 hours after you have made it. After this any unused mixture must be thrown away
8. Immediately go to the nearest health facility while drinking safe water on the way
9. Dirty clothes from the cholera patient should be washed in disinfectant /chlorine or boiled
IPC by GCHVs, HHPs, TTMs and Animators Community Drama Radio /TV spots and programmes Messages through beauty parlours/ salons / barbers Messaging through gospel singers and popular musicians SMSs/voice messages through mobile phones Wall paintings/hoardings Film shows and discussion at video clubs Messaging through town criers Communication through Nurse, Physician Attendants, Environmental Health Technicians and Doctors
IPC skills training for GCHVs, HHPs, TTMs and animators Orientation of community drama groups Development and airing of Radio/TV spots and programmes Orientation of beauty parlours/ salons / barbers Working with gospel singers and popular musicians to develop songs Working with cell phone companies to develop and disseminate messages Development and execution of wall paintings and hoardings
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Only drink safe water:
10. All drinking water should be boiled or treated with chlorine
Be very careful with food:
11. Do not eat fruits without washing: fruits should be cleaned with safe flowing water before eating
12. Food should be well cooked and eaten while hot 13. Don’t eat cold leftovers – reheat all food well 14. Utensils should be cleaned with hot water and soap,
air dried an kept in a rack above the ground Feed your child safely:
15. A child under 6 months should be exclusively breast fed and should stay with the mother as long as she is conscious
16. Cholera does not spread by breast feeding, mother’s milk is always very safe for a child even if a mother has cholera
17. Before breast feeding your child wash your hands and breasts with soap and water, especially the areas around the nipples
Your health is in your hands – keep them clean:
18. Wash your hands with soap: a. After using a latrine b. After cleaning child’s bottom c. Before eating and before feeding a child d. Before preparing food e. Before breastfeeding
19. Do not wash hands in the same water / bowl as
Motivation by religious leaders/ community leaders Peer counselling by women groups Messaging through football-based programmes
Development of a film on WASH and screening at video clubs through agreements Development of messages for town criers and providing them to town chiefs for dissemination Orientation of health care providers Orientation of religious and community leaders Formation of women’s community groups Organising football –based programmes
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other people and use running water Dispose of faeces safely:
20. Use a toilet properly 21. Construct and use a latrine if you don’t have one 22. If you have not completed construction of a toilet
bury your faeces (child’s and adult)
Primary Participants: Food Vendors
Sl.No. Current View Themes to Address Communication Methods
Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions
Do not contribute to the spread of cholera If your customer dies of cholera to whom will you sell tomorrow? Maintain the 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,
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 only unpeeled or unsliced fruits
Orientation of food vendors
Organizing orientation
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Primary Participants: Water Vendors
Sl.No. Current View Themes to Address Communication Methods
Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions
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. 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
Orientation of water vendors
Organizing orientation
Secondary Participants: Teachers
Sl.No. Current View Themes to Address Communication Methods
Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions. Unsure about role to play during an outbreak
1. You can make a difference in the cholera outbreak
2. Diarrhoea and cholera are responsible for the loss of several school days every year; hand washing with soap can reduce diarrheal disease by nearly half.
3. The habits you teach in school will protect children from
Teacher training and in-service education
Organizing the training
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cholera and also last a lifetime.
4. If you see a pupil with vomiting and diarrhoea, immediately give ORS (mixture of salt and sugar), take him/her to the nearest treatment centre
5. Ensure that the school toilet is functioning and is kept clean, to protect spread cholera by flies from the toilet
6. Don’t touch vomit. Pour chlorine over it to prevent the spread of bacteria, take the patient to a treatment centre while giving him/her ORS (or mixture of sugar and salt) or safe water on the way.
Secondary Participants: Women’s Groups
Sl.No. Current View Themes to Address Communication Methods
Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions and their role during an outbreak
1. You can make a difference during the cholera outbreak
2. Spread the word on simple precautions you and your members can take
3. Hand washing with soap can reduce diarrheal disease by nearly half.
4. Include information about hand washing in your usual activities.
5. Make sure you provide hand washing facilities and use running water and soap at youth clubs or meeting venues.
Peer education through women’s groups
Formation and orientation of women’s groups
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Secondary Participants: Religious Leaders
Sl.No. Current View Themes to Address Communication Methods Inputs
1. Low knowledge about cholera, the reasons behind it and remedial actions and their role during an outbreak
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 congregation, particularly the children among them, is at risk because they do not wash hands with soap.
4. Several lives could be saved each year through hand washing with soap??
Briefing/orientation at religious conventions and Local meetings
Organizing briefings/orientations
Secondary Participants: GCHVs, TTMs, HHPs, EHTs, PAs, Nurses, Doctors
Sl.No. Current View
Themes to Address Communication Methods
Inputs
1. 1. Importance of hand washing with soap at key times and after patient contact
2. Inform caregivers 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
Orientation of health care providers
Organizing orientation
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Annexure 6: Template for National and County Implementation Plans
National Level Implementation Plan for WASH communication & AWD/Cholera Preparedness
Sl.No. Strategy Component/Activity Responsibility Timeline Budget
1. Planning/Coordination & Research
a. Formative study on WASH (including AWD/Cholera)
b. KAP baseline
c. KAP midline
d. KAP end line
f. Formation of inter-ministerial & partner coordination group under MOHFW for WASH and AWD/Cholera communication
g. Supporting counties to develop county communication plans
h. Quarterly meetings to review implementation of plans
i. Establishing linkages with the Health Ministries in Sierra Leone, Guinea and Côte d’Ivoire to develop joint surveillance and early warning plans and communication channels and procedures
k. Carrying out mock drills to test communication preparedness and response to cholera outbreaks
2. Advocacy
a. Preparation of briefing package for media
b. Media Workshops
c. Media Visits
d. Media Fellowships
e. Media Awards
f. Programmes on WASH, AWD/Cholera on Radio/TV
g. Workshops with Senators and Legislators
h. Workshops with County /District Administration
i. Organizing a national summit on WASH to bring relevant partners together and form a consortium
j. Entering into partnership with the All Faith Association for messaging through their partners
k. Entering into partnership with Lone Star for public advocacy activities
l. Advocacy workshops with market owners associations / vendor associations
m. Identification and orientation of media spokesperson for media interaction during outbreaks
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3. Mass Media
a. Development of 4 TV & Radio spots on: - WASH - Prevention and Treatment of AWD/Cholera
b. Airing of the spots on select television channels and through community radio networks in all counties
c. Production of a 52 episode radio E-E programme on WASH including components of AWD /Cholera
d. Airing of the radio soap through national radio and community radio stations in all counties
e. Partnership arrangements with a cellular network to - Send push SMSs /voice messages to mobile subscribers - Produce and air co-branded television/radio spots - Conduct outdoor activities in public places, schools and colleges
f. Entering into partnership with popular musicians/gospel singers to develop songs promoting key WASH practices
4. Outdoor Media & Mid Media
a. Development of Hoardings and Wall Paintings
b. Putting them up at strategic locations in Monrovia
c. Supporting the counties to put them up at various locations (as per the county communication plans)
d. Entering into a partnership with a national level drama group to develop performances around WASH issues.
e. Providing technical support to drama groups in the counties through the national level group to develop and execute their performances
f. Development of film on key WASH behaviours & AWD/Cholera along with user guidebook for screening at video parlours
5. Interpersonal Communication
a. Developing a module on training of teachers for WASH promotion in schools
b. Developing a group of master trainers to train the teachers
c. Developing a training module to train GCHVs, HHPs and TTMs on IPC skills
d. Developing a group of master trainers to train GCHVs, HHPs and TTMs on IPC skills
e. Development of guidelines for orientation of beauty parlour /salon owners and barbers
f. Development of key message guidelines for Town Criers
6. Community Participation and Ownership
a. Development of module on participatory communication techniques for engaging communities
b. Identification and establishment of partnerships(county specific)
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c. Capacity building of partners on participatory communication techniques
d. Supporting counties to implement the program
7. Development of communication materials/ tools
a. Communication toolkit for GCHVs,HHPs and TTMs
b. School Communication Toolkit
c. Household calendars with key messages
d. Posters on key WASH behaviours and Cholera signs and symptoms and treatment
e. Film on key WASH behaviours and Cholera signs and symptoms and treatment
f. Hoardings
g. Wall Paintings
h. Brochures for Community / Religious leaders
i. Advocacy package for policymakers
j. Screen savers for policy makers/ administrators on WASH with key messages
k. Media toolkit/ briefing package
National Level Implementation Plan for Cholera Communication Response
Sl.No. Strategy Component/Activity Responsibility Timeline Budget
1. Development of a communication protocol for coordination of roles and responsibilities among partners
2. Carrying out weekly coordination meetings
3. Participation in sectoral rapid assessments to understand needs and prioritize affected communities
4. Revisiting and activating the detailed communication plan
a. Conducting a rapid appraisal of communication channels and resources
b. Developing a media plan for mass media initiatives and a dissemination plan for print and AV materials
c. Carrying out dissemination as per plan
d. Refresher/ orientation of community workers/ animators as required with a focus on dialogue with affected families, providing psychosocial support and tackling rumors.
f. Deployment of animators in affected areas for IPC and community dialogue
g. Activating community level structures for community mobilization activities- community meetings, household
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visits, drama shows, film shows, megaphone narrowcasts, demonstrations, communication material distribution
5. Organizing regular media briefings through the media spokesperson
6. Making arrangements to reach the poorest and those in particularly vulnerable, hard to reach or special circumstances through partnerships
7. Developing a monitoring and evaluation plan and regular collection of data through partners
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County Communication Plan implementation steps
Steps Responsible person/ department
Time frame
Objective of the step Output Output indicators Budget
County level workshop on the communication plan
Develop Communication plan
Shared understanding of key communication approaches
Identification of key messages(contextual to the identified participant groups)
Communication Plan
Action plan ready to roll out
Identify resource teams available for implementing communication activities at county/ district level
To have in place a county/ district resource group to manage/ support communication activities
Key resource team identified and engaged
Roles and responsibilities identified and communicated
Team in place and engaged
In-depth training on communication for the identified county/ district resource group
To acquaint the group on the significance and content of the communication plan
Number of resource people trained
Number of resource people skilled on communication
Individual plan developed and adopted
Select and Train town /village level mobilisers on the communication plan and use of materials
Increase knowledge on WASH issues, build skills in communication, build familiarity and skills with use of facilitation material
Number of town /village mobilisers trained
Number of skilled mobilisers
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Duplication/ dissemination of communication materials
Identification of materials available/what needs to be developed/ no. of copies required/identify recipients of the communication tools
Number of material developed
Number of recipients identified
Number of communication materials quantified with dissemination plan
Prioritize towns /villages and prepare detailed micro plan for towns/villages
Based on the assessment identify the level of activity required
Number of town/villages identified
Detailed micro-plans in place
Detailed micro plan for identified villages/towns ready for roll out
Put in place monitoring plan/mechanism
To review progress and get input to feed back in the communication strategy/plan
Monitoring plan and indicators identified
Monitoring plan with roles Responsibilities (reporting lines) and frequency
Identify funding modalities
Identify which funds will be utilized for the Communication activities
Identified budget for communication activities
(Fund utilization to be monitored by the relevant district unit)
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Template for Development of County Communication Plans
Background Information – Cover Sheet COUNTY 1. County: 2. Names and contact details of the implementing office/ partner: 3. Name and contact details of the contact Officer at County level: 4. Management/Institutional Arrangements at County level: Who will be managing communication? 5. Define:
Linkages between different district units
Human resource structure
Roles and responsibilities of units DISTRICT 6. District: 7. Name and contact details of the contact Officer at District level: 8. What are the management arrangements at District level: Who will be managing communication? 9. Define
Linkages between different district units
Human resource structure
Roles and responsibilities of unit
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TOWN/VILLAGE 10. Institutional Arrangement at Town / Village level: Who will be managing communication? Who all are involved and what are their roles and responsibilities 11. Who would be the community level communicators?
GCHVs
HHPs
TTMs
NGO Animators
12. Who will be assigned for the development and execution of monitoring and evaluation plans? 13. What has happened so far: Does a communication action plan exist? Gap analysis for existing communication plan (if any): - Barriers/Challenges - Learning’s – Positive and negative Adapted from: Sanitation & Hygiene Advocacy and Communication Strategy Framework 2012-2017, Government of India and UNICEF
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Core Components of the County Communication Action Plan Funding
Sl.No. Medium Amount
1. Interpersonal communication and community mobilization (including all IPC print material and incentive and training for Community Workers recruited for WASH)
Up to 60% (Print ceiling 10%)
2. Outdoor media – (wall painting, hoarding), drama, folk media Up to 15%
3 Mass media –Radio / print Up to 15% (Print Ceiling 3%)
4. Monitoring and evaluation of communication activities 10%
1. Training of functionaries
Level and functionaries
Subject matter/ issues
Frequency Material & logistics Budget
A. County Level
County resource group
To apprise all implementing agencies on the significance and content of the communication strategy including the WASH programme
Elements of the communication plan
Communication skills
Monitoring of communication activities
At the beginning of implementation with annual refresher
Minimum 2-3 days with maximum 25-30 participants
County resource group
Increasing knowledge and skills in monitoring and supervision
Building familiarity and skills on using monitoring formats
Building familiarity on supportive supervision
Building capacity to support research and studies for evaluations
Beginning of roll out and biannual refresher
2-3 day training with 25-30 participants
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District Level
District resource group
To apprise all implementing agencies on the significance and content of the communication strategy including the WASH programme
Elements of the communication plan
Communication skills
Monitoring of communication activities
At the beginning of implementation with annual refresher
Minimum 2-3 days with maximum 25-30 participants
Town/Village Level
Identified institutional arrangement including: GCHVs HHPs TTMs Animators Community Leaders Religious Leaders Women’s groups
WASH programme and their role in its implementation
Elements of the communication plan
Interpersonal communication skills
Build familiarity and skills on facilitation materials and monitoring formats
Their role in motivating families to adopting positive behaviors
At the beginning of implementation with bi- annual refresher
Minimum 2 days with 25-30 participants Orientation of 1-2 days
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Communication Material Costs
Material User Audience Numbers required
Unit Cost Total Cost
Outdoor media
Communication tool Location& Numbers Unit Cost Total Cost
Wall painting
Hoardings
Folk and other media
Activity Location& Numbers Unit Cost Total Cost
Drama
Folk shows
Video shows
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Mass media
Activity Channel& Frequency Unit Cost Total Cost
Radio spots
Interpersonal communication
Activity Frequency Unit Cost Total Cost
Home visits
Group meeting
Meetings organized by the village motivator
Events
Activity Frequency Unit Cost Total Cost
Celebration of Global Hand washing day
Once a year
Sanitation fairs
Recognizing cases of positive deviance
Best Family •
Best motivator/s
Best school
Once a year
Football Competitions „ 1-2 in a year
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Promoting Community Managed WASH
Activity Frequency Unit Cost Total Cost
Training for District resource group on Community management of WASH Once a year
Training of partners on Community management of WASH Once a year
Training of animators on Community management of WASH Biannual
Community Activities such as:
Community meetings
Focus group discussions
Transect walks
Mapping
Demonstration
As per plan
Additional costs
Requirements Number Unit Cost Total Cost
Man power requirements at community level
District resource group costs
Operational costs
Mobility
Office expenses
Others
Monitoring support costs
Dispatch/distribution mechanism for tools from the district level to the village/town level.
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Annexure 7: Indicators and M&E Framework
Indicators Indicators provide information on a particular circumstance that is measurable in some form. They can measure tangible things such as service uptake and also the intangible such as community empowerment and also results that were not planned. An indicator gives an idea of the magnitude and direction of change over time. Indicators could be numerical as well as pictorial such as illustrations that show the situation immediately after an emergency that are then compared with illustrations produced some time after the emergency. These can promote greater discussion and lead to a better understanding among communities. It could also include the collection of "stories from the field", which provide meaning to quantitative information or capture real "voices". This technique is known as the Most Significant Change (MSC) and has been developed for the systematic collection and interpretation of stories. Indicators are usually classified into the following types:
Outcome indicators Outcome indicators tell us whether a strategy has been successful in meeting its stated objectives. Outcome indicators can be defined by results such as behavioral change, policy change etc.
Output indicators Output indicators measure intermediate results of the communication interventions. The indicators for intermediate results can be used as predictors of behavior change. These could include changes in knowledge, attitudes etc.
Process indicators Process indicators are used to assess how well the communication plan is being implemented and to adjust communication activities and tasks to meet their objectives. They help us assesses whether inputs and resources have been allocated or mobilized and whether activities are being implemented as planned.
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Suggested Monitoring and Evaluation Framework
Results Indicators Means of Verification
Outcome Level
Increased number of individuals (men and women, and children) who use toilets regularly
Number/percentage of communities/ households having toilets.
Number/percentage of men/ women/children reporting regular use of toilets.
Base line, mid line and end line survey reports.
Increased number of children (girls and boys) who use toilets in schools
Number/ percentage of schools having separate, functional toilets for girls and boys, which are being used.
Base line, mid line and end line survey reports, Education ministry reports
Increased number of mothers/fathers/caretakers who wash their hands with soap after defecation or after having contact with faeces, before eating or preparing food, or after cleaning the child’s bottom
Number/percentage of mothers/fathers/caretakers who wash hands with soap after defecation, after handling child’s faeces, before eating or preparing food.
Base line, mid line and end line survey reports. Sales reports of soaps
Increased number of mothers/fathers/caretakers who safely dispose of child’s faeces in a latrine/toilet or safely bury it at a distance from home
Number of / percentage of mothers/fathers/ caretakers who safely dispose of a child’s faeces.
Baseline, midterm and end term evaluation survey reports
Increased number of individuals (men women and children) safely collecting, storing and handling drinking water
Number of /percentage of individual who collect water from safe sources and store and handle drinking water safely
Baseline, midterm and end term evaluation survey reports
Increased number of individuals (men, women and children) who have vomiting and diarrhoea are effectively treated/ rehydrated
Number of / percentage of individuals who use ORS when they have diarrhoea/ vomiting
Number of / percentage of individuals seek medical help when they have severe diarrhoea/ vomiting
Baseline, midterm and end term evaluation survey reports
Increased number of individuals (men and women) who take necessary
Number of / percentage of individuals who follow prescribed safety practices
Baseline, midterm and end term evaluation survey reports
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precautions at funerals and when handling dead bodies
at funerals / while handling dead bodies
Increased number of water / food vendors who practice hygienic behaviours
Number of food / water vendors following recommended practices
Baseline, midterm and end term evaluation survey reports
Increased number of individuals (men, women and children) who keep their surroundings clean
Number/ percentage of individuals who take active measures to keep their surroundings clean
Baseline, midterm and end term evaluation survey reports
Issuance of favourable policy and making of necessary administrative changes in the WASH sector by policy makers
Favourable policy / administrative guidelines issued
Policy documents, ministerial guidelines
Output level
Increased levels of knowledge and awareness regarding the importance of hand washing with soap.
Number/percentage of mothers/fathers/caretakers,who understand the need for hand washing with soap and can articulate benefits of HW at critical times.
Availability of soap close to latrines in houses and in schools.
Baseline, midterm and end term evaluation survey reports
Increase in the number of individuals (men, women and children) who are able to make linkages between hand washing with soap and diarrhea / Cholera
Number of people who are able to articulate the linkage between HW and diarrhea/ Cholera.
Number/percentage of individuals able to explain at least two critical times for hand washing
Baseline, midterm and end term evaluation survey reports
Increased number of people who stated perceived risk of not washing hands with soap at critical times.
Number/percentage of primary audience able to explain the risks of not washing hands with soap at critical times.
Baseline, midterm and end term evaluation survey reports
Increased number of people, who can identify the benefits of regular use of toilets
Number of communites/ HH having toilets.
Number of people able to articulate the benefits of using a toilet even for safe disposal of child’s faeces.
Baseline, midterm and end term evaluation survey reports
Increased number of individuals (men, women and children) who understand what to do when they have vomiting and diarrhoea
Number of / percentage of individuals who can demonstrate how to use ORS and when
Number of / percentage of individuals who know where to go for medical help when they have severe diarrhoea/
Baseline, midterm and end term evaluation survey reports
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vomiting
Increased number of individuals (men and women) who know the necessary precautions to be taken at funerals and when handling dead bodies
Number of / percentage of individuals who can articulate prescribed safety practices at funerals / while handling dead bodies
Baseline, midterm and end term evaluation survey reports
Increased number of water / food vendors who understand hygienic behaviours to be followed
Number of food / water vendors who can state recommended hygienic practices
Baseline, midterm and end term evaluation survey reports
Increased number of individuals (men, women and children) who know the importance of keeping their surroundings clean
Number/ percentage of individuals who can state what they can do to keep their surroundings clean
Baseline, midterm and end term evaluation survey reports
Increased number of senators, legislators, county / district level functionaries who stated perceived risk of not washing hands with soap at critical times and their role in relation to promoting the same
Number of senators, legislators, county / district level functionaries who are able to explain the risks of not being able to wash hands with soap at critical times
Number who can explain their role in promoting WASH
Baseline, midterm and end term evaluation survey reports
Increased number of community and faith-based leaders who stated perceived risk of not washing hands with soap at critical times and their role in relation to promoting the same
Number of community/faith-based leaders who are able to explain the risks of not being able to wash hands with soap at critical times
Number who can explain their role in promoting WASH
Baseline, midterm and end term evaluation survey reports
Increased number of teachers who stated perceived risk of not washing hands with soap at critical times and their role in relation to promoting the same
Number of teachers who are able to explain the risks of not being able to wash hands with soap at critical times
Number who can explain their role in promoting WASH
Baseline, midterm and end term evaluation survey reports
Increased number of senators, legislators, county / district level functionaries who can identify the benefits of regular use of toilets and their role in
Number of senators, legislators, county / district level functionaries who can identify benefits of using a toilet even for safe disposal
Baseline, midterm and end term evaluation survey reports
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relation to promoting the same of child’s faeces
Number who can explain their role in promoting WASH
Increased number of community/ faith-based leaders who can identify the benefits of regular use of toilets and their role in relation to promoting the same
Number of community /faith-based leaders able to articulate the benefits of using a toilet, even for safe disposal of child’s faeces.
Number who can explain their role in promoting WASH
Baseline, midterm and end term evaluation survey reports
Increased number of teachers who can identify the benefits of regular use of toilets and their role in relation to promoting the same
Number of teachers able to articulate the benefits of using a toilet, even for safe disposal of child’s faeces
Number who can explain their role in promoting WASH
Baseline, midterm and end term evaluation survey reports
Increased numbers of communities involved in the planning, implementation and monitoring of WASH programmes in their communities
Number of communities with WASH (including diarrhoea/ cholera) management plans
Number of communities involved in the implementation and maintenance of WASH facilities in their communities
Number of communities where members have contributed resources (financial, human, material) for WASH initiatives
Number of communities where WASH initiatives are led by members of the community chosen democratically
Baseline, midterm and end term evaluation survey reports Partner implementation reports, Field visit reports
Process Indicators
Policy makers and stakeholders are sensitized to the issues of WASH
Number of questions raised in house of senate and house of representatives
Number of times the issue of sanitation and hygiene brought up in public speeches
Monitoring of debates in house of senate and representatives Media reports on public engagement of concerned public figures
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Media sensitized and motivated to report on sanitation and hygiene issues and set the policy agenda and different levels of governance
Number of news stories and their prominence in International, National, County and Local media
Media monitoring and analysis
Elected representatives/stake holding ministries/department and partners are engaged and motivated to spread messages and coordinate and monitor programmes.
No. of public and coordination meetings held by elected representatives in which issues concerning sanitation and hygiene are discussed
WASH Coordination committee formed and functioning
Local media reports, minutes of meetings of national/ county /district administration
Community level communicators, school teachers, women’s groups etc. are equipped with the knowledge and skills to conduct interpersonal communication (IPC) to promote adoption of safer practices.
Number of community level communicators, school teachers, women’s groups etc. trained on use of IPC techniques.
Number of participants who can demonstrate effective communication skills„
Training reports List of participants Pre and posttest reports
An entertainment-education intervention developed and executed
Number of entertainment-education programmes organized / conducted.
Number of people reached through the programmes
Assessment reports, media/audience reports/surveys
Trainings and capacity building of key stakeholders to implement the strategy, organized
Number of trainings and consultations organized.
Number of people trained in use of communication techniques.
Training reports List of participants Pre and posttest reports
Capacities of communities built to manage WASH in their areas
Number of communities where participatory communication processes have been carried out
Number of community members / resource groups trained on identified capacity gaps
Partner implementation reports
Communication materials and tools developed and disseminated
No. of materials and tools developed
No. of copies disseminated and effectively used
No. of mass media materials developed
No. of times/ frequency of airing
List of materials, Dissemination and utilisation reports, broadcast logs, audience surveys
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Annexure 8: UNICEF’s Core Commitments for Children in the areas of Water, Sanitation and Hygiene and corresponding BCC and social mobilization support
FIRST SIX TO EIGHT WEEKS
SUPPORTIVE BCC AND SOCIAL MOBILISATION ACTIONS
1. Ensuring the availability of a minimum safe drinking water supply taking into account the privacy, dignity and security of women and girls.
Make sure that those who are providing water supplies are in dialogue with women and girl representatives to determine the best modes, times, locations and/or distribution points for water supplies.
2. Providing bleach, chlorine or water purification tablets, including detailed user and safety instructions in the local language.
Make sure the affected community and service providers receive information on the importance of and how to use bleach, chlorine or water purification tablets – i.e. through loudspeaker announcements, printed materials, and IPC.
Train motivated and interested people who live in or near the camp to provide group demonstrations on how to use bleach, chlorine and water purification tablets.
Enable service providers through communication skills and counseling training to communicate with and motivate affected individuals and families to use bleach, purify water with chlorine or water purification tablets.
Mobilize and engage community volunteers to monitor changes.
3. Providing jerry cans, or an appropriate alternative, including user instructions and messages in the local language on handling of water and disposal of excreta and solid waste.
Assess the level of knowledge on hygiene aspects in the different populations of the affected community (since it can vary widely) remembering that this is an area where most related activities are carried out by women and girls.
Ensure affected community receives information on importance of and how to handle safe water, dispose of excreta and solid waste – i.e. using a combination of loudspeakers, IEC materials, community radio, and/or peer educators.
Enable hygiene promoters, facilitators, peer educators, animators to provide one-to-one or small group participatory hygiene education.
Ensure they can handle questions and clarify doubts.
Enable service providers to communicate with and motivate affected individuals and families to wash hands, handle safe water, and dispose of excreta and solid waste.
Engage motivated school-aged children or other interested groups to observe and share information on the handling of safe water, disposable of excreta and solid waste.
4. Providing soap and disseminating key hygiene messages on the
Establish and train a team that is familiar with local practices and social structures.
Use local languages or pictograms if possible.
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dangers of cholera and other water- and excreta related diseases.
Work through existing social structures to: ensure affected communities receive soap and information on benefits of hand washing, cholera prevention and the prevention of other excreta-related diseases.
Ensure that affected communities, especially primary caregivers, know how to wash hands with soap, and how to prepare ORS to prevent dehydration, by giving demonstrations on hand washing and how to make ORS/ORT.
Train female communication agents, including community health workers, volunteers and Girl Guides to ensure women’s and girls’ access to basic health and hygiene information.
Train motivated school-aged children or other groups to demonstrate proper hand washing techniques, and for them to observe community practices as part of monitoring.
5. Facilitating the safe disposal of excreta and solid waste by providing shovels or funds for contracting local service companies; spreading messages on the importance of keeping excreta (including infant faeces) buried and away from habitations and public areas; disseminating messages on disposal of human and animal corpses; and giving instructions on, and support for, construction of trench and pit latrines
Make certain that affected community receives information on importance of and how to keep human (including infant) faeces from public and living areas, the importance of using latrines –i.e. using IEC materials (including flip charts), demonstrations on how to dispose of infant faeces/diapers.
Engage positive deviants or people who bury infant faeces and dispose solid waste properly, as positive role models.
Enable service providers to communicate with and motivate affected individuals and families to safely dispose of excreta and solid waste, safely dispose of human and animal corpses, and the use of trench/pit latrines.
Train motivated young people to be “link leaders” between camp residents and government officials – i.e. to report on broken and unsanitary facilities, observe facility maintenance and use; and help with monitoring
BEYOND INITIAL RESPONSE
SUPPORTIVE BCC AND SOCIAL MOBILISATION ACTIONS
1. Making approaches and technologies used consistent with national standards, thus reinforcing long term sustainability.
2. Defining UNICEF’s continuing involvement beyond the initial response by:
3. Establishing, improving and expanding safe water systems for source development,
Make sure the affected community has the knowledge of how excreta contaminates water and contributes to the spread of diarrhoeal disease, and the relation between unsafe water and cholera – i.e. through group discussions, children volunteers, loudspeakers, community radio, community theatre and IEC
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distribution, purification, storage and drainage, taking into account evolving needs, changing health risks and greater demand.
materials.
Mobilise the community to keep water safe – i.e. train camp residents as water source attendants who encourage people not to defecate near water sources; train support workers to chlorinate all wells and test for residual chlorine levels.
Train health workers and other service providers on specific cholera, diarrhoea prevention methods. Enable them to motivate affected community to handle safe water, purify water through boiling, chlorination or water purification tablets.
4. Providing a safe water supply and sanitation and hand washing facilities at schools and health posts.
Strengthen community knowledge of handling safe water and importance of and how to wash hands with soap, using latrines – i.e. through IPC like animators, IEC materials, etc.
Train educators, health workers, school-age children and camp/community residents to demonstrate proper hand washing techniques.
Empower service providers with tools and information to motivate school-age children and community to use latrines and to wash hands with soap or ash after defecation.
Observe pump and latrine maintenance and promote hand washing practices at schools and health posts as part of monitoring.
5. Supplying and upgrading sanitation facilities to include semi-permanent structures and household solutions, and providing basic family sanitation kits.
Involve the community in the design, implementation, and maintenance of sanitation facilities so that the facilities are culturally appropriate, private, child-friendly, accessible by the disabled – and in line with the Sphere Standards, which can be reviewed at http://www.sphereproject.org.
Enable service providers to motivate the affected community to use sanitation facilities and basic family sanitation kits.
Specifically enable female service providers or community health volunteers to communicate with girls and women about female hygiene.
Ensure that girls and women have access to appropriate materials for absorption and disposal of menstrual blood, that facilities allow the disposal of women’s sanitary napkins or provide the necessary privacy for washing themselves and for drying sanitary clothes.
Train motivated school-age children and interested groups to attend and monitor latrines – i.e. report on broken or unsanitary latrines and water pumps, observe facility/latrine use for monitoring purposes, and put up motivational IEC materials with hygiene messages, e.g. posters
6. Establishing regular hygiene promotion activities.
Identify main risk practices to adjust your hygiene promotion initiative in affected areas.
Ensure that affected individuals and communities understand good hygiene practices – i.e. by using a mix channels like street plays, traditional folk media, video showings, and other appropriate art forms that draw out local talents.
Provide supportive supervision to ensure that hygiene promoters are discussing ways to prevent diarrhoea, cholera and other excreta related diseases with affected communities – i.e. by advocating hand washing with soap or ash and the use of latrines and by organising training sessions for community and opinion leaders on
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ways to reduce risk of diarrhoea, malaria or cholera cases/outbreaks.
Mobilise community to monitor any changes – i.e. hold community meetings to discuss and share monitoring findings. Jointly decide on how the initiative can be improved.
7. Planning for long term solid waste disposal.
Facilitate water-related discussions on making safe water available.
Clearly identify the relationship between safe water, waste disposal and disease and relate those factors to action –both in the preparedness and emergency phases.
Engage affected communities in planning safe ways to dispose of solid waste – i.e. by involving them in identifying solutions and developing monitoring plans.
Source: Behavior Change Communication in Emergencies: A Toolkit, UNICEF ROSA, 2006
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Annexure 9: Useful communication channels in an emergency
Mass media The mass media include print, radio, television and cinema. When operating during an emergency, these media can reach large numbers of people in a short time. The mass media are most effective when coupled with other communication approaches through which the affected community can talk about the new information with someone whom they trust, such as community opinion leaders. Consider these points when you use mass media in an emergency:
Depending on the consequences of an emergency, the mass media can reach a substantial number of people.
Enjoys credibility.
Can be important channel for advocacy as it can reach and get the attention of policy-makers, senior officials and community leaders.
Not participatory in nature.
Messages may tend to be for general consumption, not taking into account the unique needs of the affected community.
Might reinforce gender based stereotypes (e.g. portraying women as helpless victims)
The affected population may not have access to radio or TV.
Small format community media Small format community media are often the most practical, useful and effective in reaching affected people during an emergency. These media include community radio (generator or battery-powered FM transmitters), community bulletins or flyers, and loudspeakers or megaphones - stationary (e.g., those in mosques) or itinerant (connected to vehicles). In an emergency, you can use these types of small community media to quickly disseminate information to a camp or affected community. With community coordination and support, you can plan, conceptualize, produce and disseminate messages with affected community members.
Points to consider in using small format media in an emergency:
Participatory in nature, involving all possible community groups.
Requires how-to knowledge, therefore you need to engage participants in basic training.
Easy to set up.
Needs oversight to make sure it is not abused or exploited by political factions.
Interpersonal communication channels Interpersonal communication (IPC) refers to face-to-face communication. IPC can either be one-to-one or in a small group. IPC makes it possible for people to exchange information, express their feelings and obtain immediate feedback, respond to questions and doubts, convince and motivate others to adopt certain behavioural practices. IPC requires listening skills, the ability to empathise and be supportive. IPC in a crisis situation is particularly useful in counselling approaches such as
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through hotlines, clinic consultations, in training service providers and community volunteers as peer educators, through pep talks by specialists, and for facilitating group meetings where the affected community can share and discuss the issues at hand.
Peer educators Peers are persons who belong to the same age group and social cultural background. In addition to promoting healthy behaviours, we can build local capacity by training peer educators in effective communication and participatory approaches. Even after the end of a emergency communication initiative, these individuals can continue to pass on messages through casual conversations with friends, family members and their wider peer group.
Points to consider in tapping peer educators in an emergency:
They can be easily organised in emergencies but you must invest in training which takes time.
They need supportive supervision.
Affected individuals can both give and receive information.
Does not need to be costly.
If planned and supported well, can be an effective way to motivate people.
Affected people may not have a lot of time in an emergency to participate in meetings.
Sharing personal information may not be culturally acceptable in some affected communities and will require time to establish trust.
Messages spread via word-of-mouth may diminish message accuracy.
Participatory drama Participatory drama is an important aspect in the preparedness and recovery phases. This type of communication method allows the affected community to be directly involved in the drama itself. This gives individuals greater control, and helps them to explore issues and possible solutions. Participatory performance emphasizes working with and from the affected community's own reality, and choosing their own modes of expression. Local people replace outside scriptwriters, illustrators, editors, directors and actors and become actively involved in creating and exploring solutions to a real life situation. Through participatory drama, you can encourage participation in the decision-making, implementation, monitoring and evaluation phases of relief and recovery projects.
Points to consider when using participatory drama in an emergency:
Stimulates critical thinking, stresses process rather than outcomes.
Community can prioritise their needs.
Develops a sense of community ownership.
Offers a creative approach to deal with distress and trauma and thus supports healing among affected community members.
Can be time consuming for the initial emergency response because of need to raise consciousness through IPC and relationship-building while it promotes sustainability.
Castes, class, gender and other social variables can create different realities for some members of the affected community. Be sensitive to the cultural and gender-based specifics and act accordingly, by resorting to locally appropriate and innovative means of achieving equal participation.
Community members may lack the commitment to the process if there are no perceived benefits.
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Local folk media Local folk media can include music, local art forms, local theatre, puppetry, drawing or dance. Many affected communities have their own traditional media forms to express themselves. Local ways of communicating are powerful avenues to stimulate psychosocial healing, return to normalcy and motivate affected families and communities to practice healthy behaviours.
Points to consider for an emergency:
Information can be presented in the most culturally appropriate forms.
Messages can be adapted to suit the needs of the affected community by local as well as imported experienced performers.
Most folk media are entertaining and hold the attention of the audience, allowing them to be temporarily distracted from the realities at hand.
It takes time to research on which folk media are acceptable to the affected community.
Local participants need to be identified and trained on the messages to be shared.
Technical information can be difficult to communicate.
Information, education and communication (IEC) materials IEC materials with prepared messages can be conceptualized as part of a communication preparedness plan before a disaster strikes. You can easily adapt and produce these as part of your BCC programme provided messages, design and presentation are duly pre-tested with the intended audience groups. Once a disaster strikes, producing and disseminating IEC materials can be a quick way to reach a large number of affected people. This form of communication typically leads to 'awareness raising' of an issue, and serves to reinforce existing knowledge and practices, such as the importance of hand washing, but this may not necessarily lead to changes in behaviour. IEC materials include radio public service announcements in print form, posters, leaflets, brochures, videos, flip charts, banners, and promotional items like T-shirts and badges.
Points to consider when using IEC materials in an emergency:
Generic messages addressed to and pre-tested with specific audience groups, for example, on hygiene, can be conceptualised, researched, tested and printed before a disaster strikes.
Easy to do in initial response.
Good way to get information out fast.
Awareness of message does not equal action.
Messages disseminated can easily be ignored, forgotten or cause confusion.
Each message needs repetition and reinforcement through other communication channels. When you decide on the communication channels to use in an emergency situation, keep in mind to mix media and interpersonal communication channels based on audience realities to achieve better results. Numerous communication research studies have documented that individuals are particularly influenced to adopt new or improved practices through interpersonal communication with their peers or with opinion leaders. The studies have shown that using communication materials tend to reinforce the effectiveness of interpersonal communication. Source: Behavior Change Communication in Emergencies: A Toolkit, UNICEF ROSA, 2006
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Annexure 10: How to Design a Radio Spot Depending on the impact of the disaster as well as the availability and reach of technology, radio might be a very useful channel to quickly share information and disseminate messages on health, child protection, immunization, water, hygiene and sanitation, safe motherhood or HIV and AIDS in an emergency situation. Take care to find out if the affected community has access to radio and prefers it as a communication source. This information would be best gathered in the emergency preparedness phase of your BCC initiative, but it can be explored in various participatory assessments that you facilitate in the emergency's initial response. If you find that the affected community prefers and has access to radio, and you have to design a radio spot, or judge the quality of drafts presented to you, consider following points:
Step 1: Present one idea Each radio spot should have one main message, which should be repeated several times during the spot.
Step 2: Choose a credible source of information Engage and feature a source of information (e.g. a well known public figure) that is suggested or accepted by the affected communities.
Step 3: Break the mould Try innovative ideas and formats.
Step 4: Touch the heart as well as the mind of the listener Make the listener feel something after hearing the spot or programme — happy, confident that they can do something – but make them feel.
Step 5: Stretch the listener’s imagination The voices, music and sound effects can and should evoke pictures and create images in the listener’s mind.
Step 6: Write for the ear Radio spots should have the same natural, spontaneous sound as conversation.
Step 7: Write to the individual Imagine the face of a person within your participant group and write for that person.
Step 8: Ask listeners to take action Be explicit about what the listeners can do to resolve their problem.
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Step 9: Provide consistency Develop a similarity of sound in all of your radio materials, providing continuity to the radio materials.
Step 10: Plan more than one spot Plan a serious of spots in concentrated numbers (e.g., 10 spots per evening for a week – if evening is the preferred listening time, rather than one spot per day). Source: Behavior Change Communication in Emergencies: A Toolkit, UNICEF ROSA, 2006 Adapted from: ‘A manual on communication for water supply and environmental sanitation programmes’, Water, Environment and Sanitation Technical Guidelines Series, No. 7, UNICEF New York, 1999
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Annexure 11: How to Design Print Materials Before you develop any print materials, review the behavioral objectives of your communication initiative and consider the main groups you want to reach (e.g. affected caregivers, children, health workers, teachers and/or others); whether they can they read, and if so, whether they like to read. This would be best done before a disaster strikes because it would allow for significant pre-testing, translation to local dialects, and the input of various groups within the affected community. Working on print materials pre-disaster also allows you to design materials with greater assurance that the messages and graphics are culturally, religiously and gender-appropriate. When designing print materials, keep the following principles in mind:
The number one principle is: community engagement Involve affected community members in all phases of material development – this goes beyond pre-and-post testing of your print material. Emergency preparedness allows you to engage the affected community to the fullest.
Choose a simple, logical design and layout
Present only one (1) message per illustration.
Make materials interactive and creative.
Limit the number of concepts and pages of materials.
Messages should be in the sequence that is most logical to the group.
Use illustrations to help explain the text.
Leave plenty of white space to make it easier to see the illustrations and text.
Use illustrations and images
Use simple illustrations or images.
Use appropriate styles: (1) photographs without unnecessary detail, (2) complete drawings of figures when possible, and (3) line drawings.
Use familiar images that represent objects and situations to which the affected community can relate.
Use realistic illustrations.
Illustrate objects in scale and in context whenever possible.
Don’t use symbols unless they are pre-tested with members of the affected community.
Use appropriate colours.
Use text to your advantage
Use a positive approach. Negative approaches are very limited in impact, tend to turn off the affected community, and will not sustain an impact over time.
Use the same language and vocabulary as your affected community; limit the number of languages in the same material.
Repeat the basic message at least twice in each page of messages.
Select a type style and size that are easy to read. Italic and sans serif typefaces are more difficult to read. Use a 14-point font for text, 18-point for subtitles, and 24-point for titles.
Use upper and lower case letters.
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Provide supervision for material production Without careful supervision, materials may end up in wrong colours, incorrect alignment, or careless print jobs. Have an experienced member of your team providing close supervision to the printing work.
Special Note: Combine print materials with small community media, IPC approaches and other participatory communication strategies. Printed IEC materials are most effective when combined with other forms of communication. In the initial response, print media can be used to quickly dispense life-saving messages to large numbers of affected people. Experience has shown, however, that print materials are more effective when combined with interpersonal communication. This allows the affected community to discuss the new information with someone that they trust. Source: Source: Behavior Change Communication in Emergencies: A Toolkit, UNICEF ROSA, 2006 Adapted from: ‘A manual on communication for water supply and environmental sanitation programmes’, Water, Environment and Sanitation Technical Guidelines Series, No. 7, UNICEF New York, 1999
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Annexure 12: Key Messages
Theme Messages
Hand washing Wash your hands with soap
After defecation/pupu
Before preparing foods, eating &feeding children
After preparing fish
After changing baby’s diaper
After taking care of a person suffering from diarrhoea and vomiting
Water Purify drinking water
Use chlorine or boil water
Use clean and covered water containers for transportation and storage
Food hygiene Eat only warm/ cooked food
Cook food thoroughly & eat when the food is hot/warm
Cover food and drinks to avoid flies
Wash dishes well after preparing fish
Wash fruits before eating
Avoid eating raw vegetables
Be cautious about street drinks and foods
Environmental hygiene No open defecation
Use latrine and cover the latrine hole after use - don’t defecate in the open!
Dispose children’s feaces in a latrine or dig a hole, bury and cover it
Keep your surroundings clean
Cholera Treatment Use ORS immediately if someone has diarrhoea and/or vomiting , made using safe water- boiled or treated with chlorine
Take the patient to the nearest health facility while giving ORS on the way.
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Annexure 13: Suggested Materials
Sl.No. Medium / Materials
1. Mass Media
a. TV spots
b. Radio Spots
c. Radio Drama
d. Gospel songs/popular songs CDs
2. Advocacy
a. Advocacy package for policymakers
b. Media toolkit/ briefing package
c. Screen savers for policy makers/ administrators on WASH with key messages
3. Mid Media
a. Hoardings
b. Wall Paintings
4. Interpersonal Communication
a. Communication toolkit for GCHVs,HHPs and TTMs
b. School Communication Toolkit with games and activities for children
c. Household calendars with key messages
d. Posters on key WASH behaviours and Cholera signs and symptoms and treatment
e. Film on key WASH behaviours and Cholera signs and symptoms and treatment
f. Booklets for Community / Religious leaders
g. Booklets for Beauty Parlour /Salon owners/ barbers
h. Booklets for Food and Water Vendors
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Annexure 13: Cholera – Some Basic Facts Cholera is one form of acute, watery diarrhea, a symptom that can be caused by any number of bacteria, viruses, and parasites. Cholera is caused by a bacterium, Vibrio cholerae. It is one of the most rapidly lethal infectious diseases known – it is characterized by an explosive outpouring of fluid and electrolytes within hours of infection that, if not treated appropriately, can lead to death within hours. Because of this it has become a disease that evokes fear and can lead populations to panic. However, with prompt and appropriate treatment, mortality can be kept extremely low. Furthermore, through a combination of interventions in the water, sanitation, hygiene, and health sectors, cholera outbreaks can be prevented.
Mechanism of action It is very important to understand that the bacterium itself is not responsible for disease – it does not invade the cells of the bowel wall, nor does it cause any destruction of the intestine, nor does it cross the intestinal barrier. This is quite different from the bacterium that causes shigellosis, for example, which crosses the intestine, invades intestinal cells, and causes an important inflammatory response, all of which result in a bloody diarrhea that is quite distinct from the watery diarrhea that characterizes cholera. Vibrio cholerae act by attaching to the cells that line the intestine where they produce a toxin that interferes with the normal cellular processes of absorption and secretion of fluid and electrolytes. Specifically, the cholera toxin activates an enzyme system that helps regulate the flow of fluid and electrolytes across the bowel wall and “locks” a part of what is normally a bi-directional “pumping” mechanism into a one-way outflow position. The secretion therefore becomes far greater than absorption, leading to a potentially massive depletion of water and electrolytes from the body, causing dehydration. Up to 50% of people, who develop severe dehydration, if left untreated, will die. The diagram below demonstrates this mechanism. Fortunately, because the cells of the intestinal lining have a very short life span, the disease can be of quite limited duration (as short as one day and maybe up to one week, in rare cases, with the usual duration being 3 days until the diarrhea stops), especially if exposure to the vibrio occurs only once. An understanding of this mechanism of action helps to explain why the fundamental principle of cholera treatment is rapid replacement of the fluid and electrolyte losses as they occur – if this can be done efficiently and effectively, mortality can be kept to less than 1% of those with clinical symptoms.
Mechanism of cholera action (source: CDC)
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Transmission – the ‘fecal-oral’ route The predominant route for cholera transmission is fecal-oral. There is only one way to get cholera: by swallowing something (usually water and/or food) that has been contaminated with fecal matter that contains the cholera vibrio. Consequently, if fecal material is kept out of people’s mouths, the spread of cholera can be completely stopped and infection can be entirely prevented. Other frequently cited risk factors represent only different routes of getting to this single end-step. For example, people coming together at a funeral for cholera victims do not get cholera simply by virtue of their attendance at the mass gathering – they must consume food and/or drink that has been prepared by people whose hands have been contaminated with fecal matter which contains the cholera vibrio. Although the transmission of cholera is frequently described as “person-to-person”, this can be misleading and it should be noted that the term “person–to-person” has been used in different ways by different authors. Cholera is not transmitted through the air or merely by being in close proximity to someone else that has it. Transmission is always by the feces-to-mouth route, whether the intermediary route of transmission is via water, food, hands or other means. In all cases and at all times, the key is to keep fecal material contaminated with cholera vibrio from reaching the mouth and being swallowed.
Prevention Some of the intervention areas and the justification for their prioritisation against the risk factors are presented here: Water treatment and good food hygiene - Contaminated water or food provide the best opportunity for the largest number of vibrio to enter the mouth. Therefore, if water is treated before drinking and food is well cooked before eating, a person is very unlikely to get cholera. These actions act as the last barrier before food and water enters the mouth and hence can capture the vibrio from multiple transmission routes. These should therefore be among the first priority areas for intervention along with also ensuring an adequate quantity of water to enable personal and food hygiene. Exclusive breastfeeding for under-6 month infants - An infant who is exclusively breastfed will be protected from ingesting the cholera vibrio because breast milk does not transmit the vibrio. Hence, this should also be a first priority intervention, alongside making sure that all complementary foods are made safely using the principles of good food hygiene. Hand-washing with soap at critical times – Hand-washing with soap can also prevent water and food from becoming contaminated. It will however only prevent cholera if enough of the population are practising it, because some people not washing their hands can still contaminate water and food to be ingested by others. As this is a critical part of food hygiene and keeping water clean, the promotion of hand-washing with soap should also be a first priority intervention. Effective excreta disposal – If excreta infected with vibrio is not allowed to get into the environment, then water and food will not get contaminated. However, unless open defecation is stopped and the vast majority of the population practice good excreta disposal, there will still be a risk of transmission from those who do not. Whilst ensuring appropriate excreta disposal is essential for preventing cholera happening at all, it is will be challenging to scale up sanitation interventions at the beginning of an outbreak situation to ensure the majority of the population practice safe excreta disposal. While other interventions such as water treatment, hand washing, food hygiene, etc. can start to be implemented immediately sanitation/excreta disposal should remain as a core component of the cholera response action and it should not be relegated either in priority or
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allocation of resources. Note that priority should be made to ensuring that the families of people who have been sick with cholera (who are likely to have high vibrio loads in their faeces), practice safe excreta disposal. Environmental hygiene in markets and other public places – Good environmental hygiene in market places (effective solid waste disposal and drainage) is thought to pose some risk for cholera transmission due to the increase in fly breeding near to the food on sale. There is some evidence, although limited, that flies can transmit the cholera vibrio to food, although this mechanism of transmission is expected to be relatively minor versus the direct contamination of open water sources or contamination of food or water via hands. There are additional risks of contamination particularly in urban areas where plastic bags are used for excreta disposal (which can include the cholera vibrio), but which are not collected as part of a formal scheme because these can end up being mixed with solid waste or disposed of in drainage channels. People who scavenge waste food which is disposed of in piles of solid waste may also be at risk. Good environmental hygiene in market places is a priority intervention, but after the others noted above. Vaccination – Vaccination is becoming increasingly important. There are currently two WHO pre-qualified cholera vaccines that provide protection against cholera to different degrees in different circumstances. They have the major advantage of being relatively easy to administer in a short time and, in what is considered many to be an advantage, they are dependent more on the functioning of the health system and its partners than on the actions of families or individuals. It has become increasingly clear that the appropriate implementation of a mass cholera vaccination program should always be considered as a potentially important element of any cholera prevention effort, together with the other areas of intervention. However, vaccination does not replace the need for improved water and sanitation at all levels, nor does it replace the need for rapid diagnosis and appropriate management of cases that occur, nor should it be allowed to detract from necessary on-going attention to diarrheal diseases of other origin, which remain a major cause of childhood mortality in all developing countries
Signs and symptoms of cholera The first symptoms of cholera are usually a painless watery diarrhea, frequently followed by vomiting. Fever is unusual. The volume of stool excreted during an episode of cholera is far more than with any other common cause of diarrhea and may be as much as 250ml/kg body weight per 24 hour period. Although the stool is often described as resembling “rice water”, a light brownish-liquid with flecks of solid matter in it, this is not always the case. Given the loss of copious fluid and electrolytes, dehydration can develop quite rapidly. With any degree of dehydration, the skin turgor, or the elasticity of the skin, is decreased. This is probably the most useful, and most reliable, sign of dehydration, especially in children.
Treatment There are two distinct phases in the primary treatment of cholera: 1) rehydration and 2) maintenance of hydration. In addition, antibiotic therapy is usually indicated for severely dehydrated patients and, in most circumstances, for those with moderate dehydration as well. Rehydration should be accomplished as quickly as possible to avoid complications such as renal failure, low blood sugar (hypoglycemia), or the development of excessive electrolyte imbalance (metabolic acidosis), all of which can lead to death. With appropriate and competent treatment, rehydration should always be achieved within four hours.
Source: UNICEF Cholera Toolkit, Draft version, July 2012
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Annexure 14: Key References
1. The Situation of Women and Children in Liberia 2012 – From Conflict to Peace, Government
of Liberia and UNICEF, 2011
2. Water Sanitation and Hygiene, Sector Strategic Plan 2012-2017, Government of Liberia, 2011
3. National Health and Social Welfare Policy and Plan 2011-2012, Ministry of Health and Social
Welfare, Government of Liberia, 2011
4. Essential Package of Health Services, Primary Care: The Community Health System, Ministry
of Health and Social Welfare, Government of Liberia, 2011
5. National Health Promotion Policy, Ministry of Health and Social Welfare, Government of
Liberia, 2011
6. Sanitation & Hygiene Advocacy and Communication Strategy Framework 2012-2017,
Government of India and UNICEF.
7. Knowledge, Attitudes and Practices Associated with Water Treatment, Hygiene, Diarrheal
Diseases and ORS/ORT. Liz Blanton, CDC, 2008
8. Nutrition and Hygiene Knowledge, Attitudes and Practices in Southeast Liberia by the Danish
Refugee Council. Deanne Samuels, 2009
9. Crisis and Emergency Risk Communication, CDC 2002
10. Behaviour Change Communication in Emergencies: A Toolkit, UNICEF ROSA, 2006
11. UNICEF Cholera Toolkit, Draft Version, 2012.
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No cholera and diarrhoea, in Mama Liberia!!
