Communication framework during cholera outbreaks

Annex to the:
Toolkit E – Tanzania Hygiene Communication in Emergencies Guidelines (final draft, 2010)
and
Toolkit F - WASH guidelines for cholera prevention, preparedness and control (final draft, 2010)

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

(Acknowledgements at the end of the document)

Annex 1 - Communication framework during cholera outbreaks
Key questions
What are people (examine different groups) doing
that presents a risk to hygiene and public health?
(See more detailed assessment checklist)
What feasible priority actions or practices are
required to protect their health?
What are the key obstacles that make these
practices difficult or prevent people from taking
action? (As they see it)
Summary of understanding so far
 Relatively high coverage of latrines (approx. 70%).
 Low coverage and use of improved latrines & the majority do not have handwashing facilities.
 Low prevalence of handwashing with soap in adults and children.
 Drinking water sources not protected.
 Water from water vendors not clean.
 Water is not stored or drawn safely at home.
 Children’s faeces are not seen as dangerous
 Leftover food not reheated thoroughly and fruits are not washed.
 Fruit juices and ice-lollies use contaminated water.
 Poor hygiene amongst food sellers /cooks
 Communal gatherings - food is not prepared hygienically
 Washing of deceased cholera patients leads to further transmission.
 People scared to disclose sickness or death
 Indiscriminate refuse disposal causes tips that are breeding grounds for flies
 Delay in seeking treatment
 Handwashing with soap at key times
 Treating drinking water by boiling, use of chlorine / WaterGuard or other treatment method
 ORT (ORS, zinc, other liquids and feeding) especially for children
 Using /digging latrines or improving latrines by adding handwashing facilities?
 Safe disposal of children’s faeces
 Reheating food until hot
 Cover food
 Seek treatment early, take liquid on the way
 Report cases and deaths and get professional help for the burial
 They believe that cholera is caused by witchcraft
 Do not believe that proposed solution will make a difference
 They do not think that children’s faeces are harmful
 They do not like the taste of boiled or chlorinated water
 Fear that they will not be allowed to bury their loved ones properly
Key questions Summary of understanding so far
What motivates people who already practice the (Assessment to be carried out)
desired behaviour? (Doers and non doers)
What are the different primary target or audience Mothers with young children, older women, men, school children, youths, water vendors, food vendors, people with
groups? disabilities
Who might influence the primary target groups? Traditional leaders, traditional healers, TBAs,
(Family members, friends or change agents e.g.
celebrities, sports personalities, teachers etc.)
What might influence these different target groups?  Mothers like to feel they are doing the best for their children.
 Fathers like to feel they are protecting their family.
(E.g. nurture, disgust, affiliation, convenience etc.)
 No one likes to think they might be eating shit
What are the trusted methods of communication Older women/TBAs Radio, CORPs, Street Government,
used by the different target groups? (Ask who do
you go to for advice)
What methods of mobilising communities are Religious leaders, PHAST extension workers?
available (e.g. strong leadership, religious
institutions, women’s groups, social networks, local
NGOs etc.)
What outreach workers are available? TRCS volunteers, CHWs, TBAs
What else can be done to enable men, women and Mass distribution of soap or chlorine?
children to take action? (E.g. provision of WASH
Functioning hand-washing stations next to public latrines?
facilities, distribution of hygiene items or household
water treatment technologies)
What advocacy initiatives are required at the Need for more environmental health workers? Authorities to be held responsible for producing cholera plans? Increased/
national or local level? more timely funding for cholera response?
Aim: To ensure that men, women and children are given information on how to protect themselves from cholera and are mobilised to take action to reduce the
risk of cholera

Objectives: Define objectives for each different target group

Indicators: Select 3 indicators ONLY based on priority actions outlined below. For example:
At least 25% increase in hand-washing after defaecation and before preparing or eating food, within 4 months (in target group).
At least 25% increase in use of HHWTSS, (household water treatment and safe storage) within 4 months (where promoted)
At least 25% increase in knowledge of 3 key actions to prevent cholera, within 4 months in target group

Target Group Key messages /concepts/actions desired Communication methods & Communicators/ person
locations responsible
Primary Target The primary target audience is at the heart of your communication efforts. The success of the hygiene communication will be
Audience1 measured by change or action in this group.
General Community General information in fact sheet: Household information and Community based volunteers
leaflets/fact sheet (e.g. CORPs, Red cross
Cholera is spreading through consumption of contaminated
volunteers)
food or water / made dirty by vibrio cholerae. Information provided in mosque,
church etc. Shehias, religious leaders,
Normally the disease is spread by not observing sanitation
Imams
and hygiene principles. Information provided at community
meetings, markets, bus station, Community leaders and
Absence of clean environment or a sick person contaminates
bars and clubs, clinics etc. committee members
water and food, in that way spreads disease to others who
use that water or food. National and local radio spots
1. Signs and symptoms of cholera Newspapers Water user associations
2. Mode of transmission Musical events
3. Location of treatment centres Mobile video units (note – could
use experience of people severely
4. Preventative & control measures: see below (personal Name radio stations and
affected by cholera in Pemba to
hygiene, food, water, environmental sanitation & hygiene, contacts
prepare a video to influence others)
home based care with ORS / fluids/ funeral safeguards)
1
The messages for the primary target audience were compiled by an interagency working group in response to the cholera outbreaks in 2010
Target Group Key messages /concepts/actions desired Communication methods & Communicators/ person
locations responsible
a. Do not drink local brew during cholera outbreak Public address system
b. Do not hide a patient with cholera symptoms – take Lamgambo Clinic staff/ Environmental
him/her immediately to the treatment centre health officers
Mobile phones
Your health is in your hands – wash your hands with soap and
flowing water:
District health committees
1. After helping someone who is sick
2. After visiting/using toilet
3. After touching child’s faeces (after cleaning child’s bottom)
4. Before eating and feeding a child
5. Before preparing/cooking food
6. Before breast feeding your child
Gatherings are contributing to spread of cholera
1. Avoid gatherings during cholera outbreak
2. It is not allowed to eat or drink at any gatherings e.g. at
funerals or celebrations, weddings, open markets etc. during
cholera outbreak
3. Bodies of people who have died of cholera are very infectious
Mothers (of young What to do if you or your child has diarrhoea and vomiting: Household visits TRCS, CHW, TBAs
children)
1. Use ORS immediately made using safe water (boiled or
treated with chlorine)
Information given by outreach NGOs, extension workers
2. In case you don’t have ORS drink plenty of safe water workers and volunteers at women’s
group meetings
3. Immediately go to the nearest health facility while drinking safe
water on the way
4. Dirty clothes from the cholera patient should be washed in Information and leaflets provided at
disinfectant /chlorine or boiled clinic Nurses and doctors
Only drink safe water:
1. All drinking water should be boiled or treated with chlorine
Be very careful with food: Religious leaders
1. Do not eat fruits without washing: fruits should be cleaned with
Target Group Key messages /concepts/actions desired Communication methods & Communicators/ person
locations responsible
safe flowing water before eating
2. Food should be well cooked and eaten while hot
3. Don’t eat cold leftovers – reheat all food well
Feed your child safely:
1. A child under 6 months should be exclusively breast fed and
should stay with the mother as far as she is conscious
2. Cholera does not spread by breast feeding, mother’s milk is
always very safe for a child even if a mother is having cholera
3. For a child above 6 months should not be given cold food,
heat it thoroughly
Your health is in your hands – keep them clean:
1. Wash your hands with soap:
 After using a latrine
 After cleaning child’s bottom
 Before eating and before feeding a child
 Before preparing food
 Before breastfeeding
2. Do not wash hands in the same water / bowl
Dispose of faeces safely:
1. Use a toilet properly
2. Construct and use latrine if you don’t have one
3. If you have not completed construction of a toilet bury your
faeces (child’s and adult)
4. Make sure a toilet is always clean
Primary School 1. If you see a pupil vomiting and diarrhoea, immediately give Include in school lessons and Teachers
Children ORS (mixture of salt and sugar), take him/her to the nearest assembly
treatment centre
Information: posters / flyers on
2. Yes – as a precaution we are required to always drink safe school notice boards and other
Target Group Key messages /concepts/actions desired Communication methods & Communicators/ person
locations responsible
water boiled or treated prominent places Environmental health staff.
TRCS staff and volunteers
3. Be careful with foods-don’t eat cold or open food Drama
4. It is essential to use toilet when you are at school and at home. Competitions, games
Toilets should be kept clean, to protect spread cholera by flies NGOs working with children
Music
from the toilet
Children’s councils
5. Wash hands with clean water and soap after visiting toilet or
Shehias, religious leaders,
after playing and before eating. Peer educators
Imams
6. You should also wash your hands if you help to feed a young Information given at parent groups
child or change his/her nappy or after helping a sick person
Madrassas and Sunday schools
7. No - you should not eat fruits that are not washed well
8. Don’t touch vomit, spread chlorine to protect spread of
bacteria, take the patient to treatment centre while giving
him/her ORS (mixture of sugar and salt) or safe water on the
way.
9. Yes - you must inform the teacher as soon as possible
Secondary School 1. As above Leaflets, booklets MOE
Children
2. Spread the word and help protect your family and community Peer educators

Food & Fruit Vendors Do not contribute to spread of cholera

If your customer dies of cholera to whom will you sell Fact sheets Environmental health officers
tomorrow?
Maintain good health of your customer
Rapid orientation/training and Market inspectors
1. Clean utensils with hot water and soap certification system?
2. Keep utensils clean
Community volunteer
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,
Target Group Key messages /concepts/actions desired Communication methods & Communicators/ person
locations responsible
7. Prepare food in clean environment
8. Wash fruits and vegetables that are eaten raw with
safe water
9. Sell unpeeled and unsliced fruits
Water Vendors Sell clean and safe water (a vendor who cares for his
customers sells them safe water, sells water from safe
Fact sheets EHOs
source)
Water department
1. Collect water from safe sources
Rapid orientation
2. Keep the surroundings of the water source in clean and
hygienic condition, avoid haphazard spilling of water NGOs
3. Do not allow buckets or containers to be contaminated through Public address
poor drainage or putting buckets inside each other
4. Wash your hands with soap before fetching / collecting water
5. Use appropriate water storage and clean containers regularly
with soap and water
6. Water containers should be cleaned regularly
7. Advise your customers to boil all water or treat it with chlorine
during a cholera outbreak, as any water can be contaminated,
even if it looks clean
Depending on the source:
1. Chlorinate water source & monitor the chlorine residual
Other (i.e. identified
as a result of ongoing
assessment during
response)
Secondary Target The secondary target audience is in a position to influence the primary target audience. The above message/actions/concepts
Audiences2 will also apply to the secondary target audiences but additional messages may also be important
Teachers 1. You can make a difference in the cholera outbreak Teacher training and in-service MoE
education
2. Diarrhoea and cholera are responsible for the loss of hundreds

2
These messages are examples only and have not been ratified by the interagency working group
Target Group Key messages /concepts/actions desired Communication methods & Communicators/ person
locations responsible
of millions of school days every year; handwashing with soap
can reduce diarrheal disease by nearly half.
3. The handwashing habits you teach in school will last a lifetime.
4. You can easily include handwashing with soap in many
lessons.
5. Making HW stations is a good activity for school children and
can influence their families.
Religious Leaders 1. You can make a difference in the cholera outbreak Briefing/orientation /leaflets at MOHSW
religious conventions
2. Many religious faiths call for washing and cleanliness before
prayer or during other religious rituals; only hands that have Local meetings
been washed with soap are truly clean.
3. The health of your congregants, particularly the children
among them, is imperilled by lack of handwashing with soap.
4. One million lives could be saved each year through
handwashing with soap??
Youth 1. You can make a difference in the cholera outbreak MOHSW
groups/women’s
2. Spread the word on simple precautions you and your members
groups etc.
can take
3. Handwashing with soap can reduce diarrheal disease by
nearly half.
4. Include information about handwashing in your usual activities.
5. Make sure you provide handwashing facilities and use running
water and soap at youth clubs or meeting venues.
Journalists, radio and 1. Key facts about cholera prevention and control addressing Ministry of Communication
TV producers myths, beliefs and practices and Transport
Press conferences
2. Signs and symptoms MOHSW
Media Briefings
3. Mode of transmission Media NGOs
Fact sheets
4. Prevention and control measures (hand-washing WITH SOAP,
Website
latrine use, food hygiene, personal hygiene etc)
5. Treatment centres
Target Group Key messages /concepts/actions desired Communication methods & Communicators/ person
locations responsible
6. Use of home based care (ORS) and fluids
7. Where to get information – Outbreaks alert / Early Warning –
the MOHSW reports on outbreaks every Saturday to the radio
Clinic health staff 1. Importance of hand-washing with soap at key times and after Flip charts MoHSW
patient contact
Leaflets
2. Inform carers that they should disinfect their homes in all areas
Discussion with patients and
where there have been vomit and faeces
relatives
3. Use the opportunity of helping people to disinfect their homes
Reminders (cues for action) e.g.
to also investigate if anyone else is sick and provide
posters at hand-washing points
information to family members and neighbours
Tertiary Target The tertiary target audience comprises decision makers and funders who can contribute to the success of the programme
Audience

Government Ministers Impact of cholera on your community Briefing paper MoHSW

What you plan to do about it and what support you need Proposals
 WHO?
Who will lead/co- RMO/RHO
ordinate hygiene
DMO/DHO
communication
efforts? (E.g. lead ZMO
agency, committee,
working group etc.)
What human RHMT members
resources are
available to
communicate
hygiene?
Environmental health officers
Clinic /health centre staff
VDC/VC Mtaa members
What other ministries Ministry responsible for
should be involved? information and communication
(mass media department)
Ministry responsible for
community development
Ministry responsible for
agriculture
Ministry responsible for water
Ministry responsible for education
Ministry responsible for sanitation
What other partners Political leaders at ward and
should be involved? national level
WHAT is their role with regard to hygiene
communication during response?
Mobilization of resources
Co-ordination
Promote use of policies and guidelines
Surveillance of food outlets
Supervising burials
Community education and mobilisation
Hygiene education in clinics
Community education and mobilisation
Mass mobilisation and sensitization
Community sensitization and mobilization
Food safety
Safe water supply/ water user committees
Primary, secondary and tertiary education
Sanitation
Mobilization of resources and budget approval
Action required now to prepare for future
response?
Review policies and guidelines
Supervise implementation of HIMS
Oversee emergency preparedness plans
(including hygiene communication plan)
Capacity assessment
Contribute to policy and guideline review
Convene planning and co-ordination meetings
Ensure local plans are in place
Training on emergency response and update on
hygiene communication
Training on emergency response and update on
hygiene communication
Training on emergency response and hygiene
communication
Advocacy for access to radio airtime
Invite to planning meetings
Invite to planning meetings
Involve in planning meetings
Involve in planning meetings
Involve in planning meetings
Training on emergency response and hygiene
communication

UNICEF/WHO Financial and technical support
TRCS Mobilization of volunteers and additional funding and
resources for implementation
NGOs Direct implementation where resources allow. May
have networks of community volunteers
PSI Technical support on collaboration with mass media,
mobilization of resources and funding, networks of
community change agents
CBO/ FBOs Community mobilization
Local media (especially radio Mass dissemination of information
stations)
Convene local planning meetings
Support for government plans
Collaboration with the MOHSW / MOH and
others
Collaboration with MOHSW / MOH and others
Collaboration with MOHSW / MOH and others
Training and capacity building
Briefings
Meetings to discuss opportunities for
collaboration
Outcome Indicators Who should monitor this? How? Tools and Resources. How often?
A 25% increase in mothers with young children washing Community leaders General: Observation, discussion, questioning Each visit/contact
their hands with soap at key times (after going to the toilet,
Community Volunteers Specific: Random sample questionnaire Weekly
cleaning their babies’ bottom, eating, breastfeeding and
survey and FGDs
preparing food) Field based NGOs
Clinic staff
A 25% increase in households correctly using WaterGuard Community leaders General: Observation, discussion, questioning Each visit/contact
to treat drinking water (where promoted)
Community Volunteers Specific: Random sample questionnaire Weekly
survey
Field based NGOs
Clinic staff
A 40% increase in households who can list 3 key ways to Community leaders General: Observation, discussion, questioning Each visit/contact
prevent the spread of cholera (if your objective is to provide
Community Volunteers Specific: Random sample questionnaire Weekly
information)
survey and FGDs
Field based NGOs
Clinic staff
Where provided, WASH facilities are being used and Community members Observation Each visit
maintained adequately by all members of the target
Community leaders Spot checks
population.
Community Volunteers
Field based NGOs
Output Indicators
Hygiene communication plans and materials that use both Local administration Observation Within 3 weeks of
the mass media and interpersonal communication response
MoHSW Interviews with key informants
approaches are in use.
WASH NGOs
Hygiene communication training and orientation for all MoHSW Observation By week 8 of response
implementers and secondary target audiences has been
MoE Interviews with key informants
carried out and reviewed.
WASH NGOs
Information on the response is regularly provided to Community volunteers Observation By week 8-12 of response
affected communities and feedback and complaints
Field workers Interviews with key informants
mechanisms are in place.
FGDs

Process Indicators

Communication materials have been developed with the Fieldworkers FGDs Ongoing
target audiences and are interesting, acceptable and
MoHSW Observation
visible
WASH NGOs

The majority of participants in FGDs feel that they have Field based NGOs Discussions with affected communities Each visit/contact
been provided with adequate information about the
Independent assessor FGDs After 1 month then every 2
response and that field workers are working collaboratively
months
and respectfully with them.
 Additional – for health care workers
Objectives
To help save lives through
appropriate actions, to
prevent transmission of
cholera in health facilities
Key Messages for Health Care Workers
Key Messages Communication
methods and channels
Patient isolation: Training of health staff
1. Treatment centre to work on a triage – with separation of observation, mild and severe cases Instruction notices /
posters
2. Access within the centre to be limited to staff and one carer per person
Guidelines
3. If possible separate women and men patients, even if by a screen
General and patient hygiene in CTC:
4. Disinfect and contain all faeces and vomit
5. Provide separate toilets and bathing units for patients and carers to staff
6. Strict hygiene procedures to be undertaken at all times – hand-washing with chlorinated water,
footbath at entrance
7. All ground surfaces to be fully cleanable including the latrine
8. Protective clothes to be worn in the centre by staff – overalls, gloves, plastic apron, gum boots
9. Disinfect clothes and bedding of infected people before they leave the centre – either with
chlorinated water or by boiling
10. Neutral area to be provided for food preparation, staff resting, storage
Use appropriate chlorine solutions:
4. 2% solution – waste and excreta, dead bodies
5. 0.2% solution - floor, objects / beds, footbaths, clothes, house spraying
6. 0.05% solution – hands, skin, surfaces of transport
7. Drinking water – use WaterGuard (liquid or tablet)
Food for patients, carers and health staff:
8. Food only to be prepared in the centre
Hygiene outside the centre:
1. If people arrive in public transport the vehicles should be disinfected
2. People’s houses should be disinfected in all areas where there have been vomit and faeces
3. Use the opportunity of helping people to disinfect their homes to also investigate if anyone else
is sick and to do hygiene promotion with family members and neighbours
Acknowledgements for the series of emergency WASH toolkits, 2010
These toolkits have been developed by members of the Water, Hygiene and Sanitation
(WASH) sector in Tanzania as part of a series of emergency WASH toolkits in 2010.

A wide range of people have been involved in their development, starting from a cross-
Ministry and inter-disciplinary team who developed the communication framework for cholera
emergencies and the cholera IEC materials in 2009. This was followed by a review of the
emergency hygiene promotion activities from the previous year in mid 2010, and the
development of the emergency hygiene promotion guidelines. This was undertaken with the
facilitation of an international consultant from RedR, Suzanne Ferron, Husna Rajabu,
MOHSW, Health Education & Promotion Unit of the MOHSW, and Justus Olielo from
UNICEF. Suzanne Ferron produced the first version of the Hygiene Communication in
Emergencies Guidelines and assisted the sector to strengthen the Communication
Framework, developed at an earlier stage by the sectoral team.
Organisations who have participated in these processes include but are not limited to: CMO-
DMD; Concern Worldwide; Help Age; MoEVT (Mainland); MOH (Zanzibar); MOHSW
(Mainland – Epidemiology, EPR, Environmental Health, Health Promotion); MOW
(Mainland); MOW (Zanzibar – Unguja and Pemba); PMO-DMD; PSI; TRCS; UNICEF; WHO;
ZAWA; Handeni, Magu, Kasulu, Kigoma, Kilosa District Councils; and Mwanza Regional
Secretariat.
Materials have also been used from the RedR supported training in 2010, for Emergency
WASH for Cholera, Flooding and Displacement. The RedR facilitators for this training were
Eric Fewster and Ritva Janti with the support of a range of co-facilitators from the Tanzanian
sector and also from the International Federation and Red Cross Society in the East Africa
regional office and the UNICEF ESARO regional office.
Following the key activities noted above, a sub-group focusing on capacity development for
the Tanzanian emergency WASH sector continued on to develop the full set of toolkits.
Members of this sub-group include: Burton Twisa, Concern Worldwide; Hijja Wazee,
HelpAge Tanzania; Salum Abubakar, Ministry of Health, Zanzibar; Clement Chacha and
Susan Nchalla, Environmental Health & Sanitation Unit, MOHSW; Mrs Husna Rajabu,
Health Education & Promotion Unit, MOHSW; Dr William Kafura, Epidemiology, MOHSW; Dr
Faraja Msemwa, Emergency Preparedness and Response Unit, MOHSW; Kheri Issa
Ngwere, Abdallah Bunga and Adam Karia, Tanzania Red Cross Society; Rebecca Budimu,
Daudi Makamba and Sarah House, UNICEF.