Emergency community education and engagement strategy for acute watery diarrhoea (AWD) prevention and control in Ethiopia
This brief outlines measures that ought to be taken to enlist community participation in AWD prevention and control. The concept underscores the challenges posed by the fast spreading outbreak, the predisposing factors and the need to educate the community in both affected and unaffected areas. The thrust of this concept is immediacy, maximised reach (using all available means), appropriateness (based on what the community can do by themselves using what is at their disposal) message positioning (using local idioms and situations) in educating and engaging the community. An initiation pilot to test the suggested approach and get community feel has been proposed to take place in 6 zones in Oromiya region beginning early November.
1.0 Important facts
¨ AWD was first reported in 2 Woredas of the west arsi zone of the larger Oromiya region way back in June 2006
¨ The outbreak quickly spread to 3 other within the zone and by Mid August had reached the neighbouring zones of Guji.
¨ By mid October AWD had spread to five more regions of SNNPR, Tegray, Amhara, Afar, Somali and Addis Ababa.
¨ To date about 30,000 cases and 300 deaths have been reported (this reports are based on information received from CTCs and figures could be higher than this)
¨ The sanitation situation in most regions (less than 10% on average) in rural Ethiopia and cultural practices (e.g eating raw meat) can support quick spread of a faecal oral related disease like AWD
¨ Most of the rural areas are not easily accessible and a quick spread to these areas would be overwhelming both to the government and participating organisations
¨ There is little presence of NGOs and functional government health structures at the inaccessible rural areas
¨ Rural communities in both rural and urban Ethiopia are highly mobile.
¨ In short, the AWD is already overwhelming, is spreading quickly and has great potential to spread even further.
2.0 Efforts undertaken so far
¨ UNICEF, MSF, Merlin and ACF have supported the Oromiya health bureau to establish case treatment centres in West arsi and Guji zones. The support has been mainly inform of CTC supplies, CTC infrastructure, setting up of CTS, trainings and provision of WATSAN supplies (water purification chemicals and soap)
¨ PSI has undertaken hygiene education TOT trainings (targeting community health workers at Kebele level) and provision of water guard (home based chlorine formulation) in both West arsi and Guji
¨ Environmental health officers from the two zones and nursing upgrade students on attachment have been undertaking community education through capture audiences and on exit from CTCs
¨ Since the establishment of the CTCs, the case load has gone down from 380 cases per day in west arsi to less than 40 cases per day in three weeks
3.0 Gaps identified in the current efforts
¨ During a visit to West arsi and Guji (between 2nd and 10th September) it was noted that despite all the efforts that have been put in these two zones, there are still AWD related deaths occurring (mainly at community level). It was also noted that the outbreak was spreading to neighbouring villages.
¨ During the same visit discussions held with community members in the two zones indicated that although a lot of efforts had been put in hygiene education and promotion, the community found it too ‘heavy’ to take in and implement immediately. They also did find it as the same common messages they have heard over the years and did not find anything new – the only new thing was the rate at which the disease was spreading and killing. In other words, the community did not find any urgency in the message and did not feel engaged.
¨ Further discussions with zonal health representatives and participating organisations indicated that all the community education undertaken so far has been based on the conventional hygiene education.
¨ Thus a clearly designed AWD specific emergency community education and engagement approach to hygiene education and promotion was identified as lacking.
4.0 What is required
There is urgent need to repackage the existing hygiene education an promotion into an emergency community education and engagement plan that is:
1. AWD Focused – narrow down to feasible target practices that would impact directly and rapidly to the reduction of the spread and control of AWD. Should focus on both community based prevention and severity reduction approaches
2. Community oriented – be based on practical actions that the community can afford to take immediately by use of materials at their disposal. Must be attractive, positive, and engaging and which provides visible demonstration that the community can make positive impact by using what they have at their disposal
3. Rapid – the plan should spell out ways of rolling it out as quickly and as widely as possible
4. Maximum reach – the plan should make provision for a roll out throughout the country
5. Cost effective – The implementation plan would need to balance coverage and cost effectiveness. Delivery channels should work out the cost per capita of each form of communication and then select a mix of communication channels, which balance maximum reach and maximum effectiveness.
6. Message positioning - the messages given to the community should be repackaged to make them easy to understand, attractive and provocative by use of local idioms and situations. Messages should be region specific to incorporate cultural differences and locally available materials at communities’ disposal.
4.1 Repackaged community education and engagement messages
After thorough discussion with federal ministry of health officials and participating organisations AWD specific messages were narrowed down to five main themes. This was in consideration of the above aforementioned key principles:
1. Safe excreta/vomitus disposal
SAFE = CONTAINED * (messages to focus on safe ways of containing excreta/vomitus by use of simple methods that the community can adopt immediately – e.g. burying/covering with soil and/or banana leaves for rural communities without latrines)
2. Hand washing – breaking the chain
RUB IT OFF WITH ASH OR SOAP * (messages to focus on the need to use a scoring agent to clean hands at key times e.g ash which is readily available in rural areas)
3. Drinking water treatment at point of use
BEFORE DRINKING, TREAT IT! * (Messages to focus on water boiling for rural communities and use of water guard for urban and peri-urban communities where it is available)
4. Food hygiene
NO RAW FOOD* (messages to focus on advising the community to stop eating raw food during the outbreak period)
5. Home-based oral rehydration
REPLENISH LOST FLUIDS AS YOU WALK TO THE NEAREST HEALTH POST REMEMBER THAT WHAT GOES OUT MUST GO BACK IN * (messages to focus on formulating safe drinks available at communities disposal to ensure glucose/salt balance e.g sugar salt solution (SSS), Bulla Kocho (common light porridge rich in carbohydrates and mixed with salt used for breakfast in most rural communities – made from false banana extract). Also advice the community to drink after every episode of diarrhoea/vomiting as they walk to the nearest CTC/health post)
4.2 Target audience segmentation and message positioning
Target audience / Who / Where / Channels of communication / ObjectivePrimary / Parents (Mothers), school children / Schools, home, markets, fields, / School forums, National and regional radio spots and interactive discussions, Communal gatherings, home visits, street theatre / Get information about the danger posed by AWD across
Engage the community to take action
Secondary / Teachers, religious leaders, community leaders, Health Extension Workers, Agricultural Extension Workers, PA Leaders, students from medical colleges, volunteers, capture audiences / Organised forums, churches, Mosques, temples, existing community structures, meeting places, bars, sports / Organised forums and TOT trainings, Seminars, National and regional radio spots and interactive discussions, TV, meetings, print media, leaflets, special events / Support awareness creation campaign and act as agents of change in areas of jurisdiction
Tertiary / Government, partner agencies, donors / Interactive and coordination meetings / Leaflets, radio, TV, meetings, seminars, ceremonies, print media, workshops, internet, special press / Support the rapid result oriented hygiene education strategy and pool resources. Monitor progress and fine tune
4.3 Step by step implementation of the repackaged community education and engagement plan
1) Sell the idea to other partner organisations and the ministry of health during coordination committees meetings.
2) Engage all the partners and the government in developing standardized message package and dissemination channels
3) Pilot the plan in the areas where partners are working. Localise the messages according to cultural peculiarities in different regions.
4) Make adjustments as per pilot results and pool resources together to fund a rapid nationwide community education and engagement
5) Keep close monitoring of the outbreak trend and gauge communities participation in various regions. Make adjustments as necessary.
4.4 Initiation Pilot in Oromiya region
The first pilot for this repackaged approach has been planned to take place in 6 affected zones in Oromiya regions. The pilot will take place in Guji, Arsi, Bale, Borana, West arsi and East Shoa zones. The target of the pilot will be to induct schools (both primary and secondary) Red Cross and health club patrons, representative religious leaders and health professional from each woreda in Guji zone. Only health professionals from the other five zones will be trained. The messages have been localised into Oromo idioms and expressions and adjusted to include locally available materials and beliefs. The workshops will be organised and coordinated by the respective host zonal health offices while the trainings will be conducted by jointly by UNICEF and Dr. Woudneh of Oromiya health bureau.
The following participants from each Woreda have been proposed to attend the induction workshops:
Uraagaa (57 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 50 schools in the Woreda (both urban and rural) – total 50
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Dama (27 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 20 schools in the Woreda (both urban and rural) – total 20
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Boree (67 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 60 schools in the Woreda (both urban and rural) – total 60
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Qarcaa (52 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 45 schools in the Woreda (both urban and rural) – total 45
4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Adoolaa(46 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 30 schools in the Woreda (both urban and rural) – total 30
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
O/Shaakkisoo(61 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 54 schools in the Woreda (both urban and rural) – total 54
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Girja (22 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 15 schools in the Woreda (both urban and rural) – total 15
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Bul. N/M Adoolaa (13 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 8 schools in the Woreda (both urban and rural) – total 8
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 Muslim and1 traditionalist)
Liiban (52 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 45 schools in the Woreda (both urban and rural) – total 45
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Waadaraa (33 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 26 schools in the Woreda (both urban and rural) – total 26
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Bul. N/M Nageelllee (17 participants)
· 6 health professionals
· 1 teacher from each of the 7 schools in the town – total 7
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and 1 traditionalist)
Meda Waraabuu (42 participants)
· 3 health professionals from the woreda
· 1 teacher from each of the 35 schools in the Woreda (both urban and rural) – total 35
· 4 religious leader representatives (1 Orthodox, 1 protestant, 1 muslim and1 traditionalist)
In addition health professionals from 5 other affected zones will be inducted on a 2 days TOF workshop and provided with training materials to conduct training fro teachers in their respective worendas. The targeted zones are as follows:
Health professionals from other zones (116 participants)
· Bale zone - 2 participants from each of the 16 Woredas – total 32
· Borana zone - 2 participants from each of the 10 woredas – total 20
· Arsi zone – 2 participants from each of the 20 woredas – total 40
· East Shoa – 2 participants from each of the 12 woredas – total 24
· West Arsi - 2 participants from each of the 10 woredas – total 20
Expected workshop output
· A total of 461 teachers will be orientated on the repackaged approach to AWD prevention and control strategy. Each of the teachers will give a one-day training to all the red cross/health club patrons in their worendas who in turn will train students/pupils in their respective schools. Posters will be provided for each school. An impact assessment will be conducted in the villages two weeks later to find out how well the students/pupils will have driven the messages home and level of practice.
· A total of 36 religious leaders will participate in the training. It is expected that they will re-emphasize the repackaged messages during meetings with their congregations.