My Piece of Zed: A Novel Adolescent-driven Behaviour Change Communication Strategy to Eliminate Cholera in Zambia 2025

PolicyBriefǀDecember2019

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Summary

• Sustainedlong-termcholerapreventionbehaviouralinterventionsareurgentlyrequiredtoachieveeliminationofcholerainZambiabytheyear2025.

• WeproposeanadolescentfocusedbehaviouralinterventiontitledMyPieceofZed,thefirstofitskindtobebornfromlocallyderivedevidenceandbehaviourscience,toimprovethreebehavioursproventobecriticaltointerruptfaecaloraltransmissionofcholeraamonghouseholdmembersinbothruralandurbanZambia.

• WerecommendthatMyPieceofZedbepilotedfornationalscale-upinordertosustainbehavioursthatwilleliminatecholerainZambiabytheyear2025.

Rational Recently,Zambiabecameoneofthe35membercountriestotheGlobalTaskForceonCholeraControl(GTFCC)withthemandateofeliminatingcholerabytheyear2030(1).Tothiseffect,theZambiangovernmenthasdevelopedamulti-sectoralplanwithanambitiouslegacygoaltowardscholeraeliminationby2025.Thisplanmandatesstakeholderstodevelopabehaviourchange communication strategy by the year 2019, implement the strategy by 2022 andreinforcethestrategyupto2025.The Centre for Infectious Disease Research in Zambia (CIDRZ) and the London School ofHygiene and Tropical Medicine (LSHTM) in collaboration with the Zambia National PublicHealth Institute (ZNPHI) embarked on preliminary formative research to develop aninterventionthattargetsthemostrelevantbehaviours intheZambiancontext.Stakeholderconsultations and a literature review identified handwashing with soap after contact withfaecesandbeforeeating,householdwatertreatmentwithliquidchlorineaftercollectionandre-heating of stored cooked foods before consumption as critical for cholera prevention.Currently,thesebehavioursarepoorlypracticedinZambiancommunitieswithaboutathird

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washingtheirhandswithsoapandtreatingtheirwaterbeforedrinkingit[2].Noevidencewasfoundonfoodre-heatinginZambia.

InsightsfromtheFormativeResearch Weconducted formative research,employingnon-traditionalqualitativemethods includingbehaviour trials,motivemapping, [3]andup to24hrsparticipantobservations inKanyamacompound(urban),Lukangaswamps(fishingcommunity)andtwovillagesinChiengidistrict(rural).Thesemethodsprovidedthefollowinginsights:

§ Inallthreecommunities,thethreebehaviourswererarelyandinconsistentlypracticed(lackofanestablishedroutine)amongobservedhouseholds.

o The lack of a conveniently located and provision forwater and soap detershandwashingwithsoapaftertoiletuse.

o Handwashingwithsoapbeforeeatingmainmeals(nshima)isavoidedduetosmellthatinterfereswithtaste.

o Duetolackoffacilities,fishermenusetheLukangaswampstomeettheirwaterandsanitationneeds,includingdefecation.

§ Whilepeopleknowthatdrinkingwatershouldbe treated, theydependonchlorinedistribution by the local clinic rather than purchase the product; and boiling is toocumbersome.

§ While storingdrinkingwater in a narrow-mouthed container lessens contaminationthroughuse,peoplepreferwide-mouthedcontainersforeasycleaninganduse.

§ Left-overfoodiswellstoredbutisre-heatedtoimprovetasteandavoidstomachachesandnauseaandnottoavoiddisease.

§ Fear of choleramotivates handwashingwith soap and householdwater treatment,evidencedbythereportedincreaseinthesepracticesduringcholeraseason,however,thismotiveisshortlivedoncetheriskofcholeraisreduced.

§ While,mothersfeelresponsibleforensuringthatallhouseholdmemberspracticethethree desired behaviours, they reported easily forgetting to practice and promotethesebehavioursastheyarebusywithsomanyhouseholdchores.

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PolicyRecommendationsThebelowrecommendationsareproposedforthebehaviourcommunicationstrategyoftheZambiaMulti-SectoralCholeraEliminationPlan.

1. Targetingthe‘mother’foracholerapreventionbehaviouralinterventionmayhaveminimaleffectduetoherhouseholdandcaregivingresponsibilities.Werecommendtargetingadolescentsagedbetween15and19yearsoldtobethebehaviourchangeagents.YouthmakeupasignificantportionoftheZambianpopulation[4]andarethemostaffectedduringacholeraepidemic[5].

2. Themaininterventionmustbetheory-andevidence-basedandmust

translateintoawell-thoughtoutengagementstrategywithactivitiesthatstronglymotivateadolescentstoimprovehandwashingwithsoap,householdwatertreatmentandfoodre-heatingbehaviourswithintheircurrentsetting.

3. Theinterventionshouldnotbeassociatedwiththepreventionof

choleraoranyotherdiarrhoealdisease,assuchmessagingdoesnotsustainbehaviour.Rather,theinterventionshouldappealtoahighermotivesuchasstatus,affiliationorplay.

4. Thedesignedinterventionshouldbeimplementedbeforethecholera

seasonandshouldcontinueduringandafteracholeraoutbreaktopromotesustainability.

5. Theprivatesectorshouldbeengagedtobuildinsocialmarketing

strategiestoensureaconstantsupplyofliquidchlorine,soapandotherproductslikefoodstoragecontainers.

6. TransientpopulationssuchasthoselivingintheLukangaswamps

urgentlyrequirefurtherresearchtounderstandtheircholeratransmissionpathwaysbetter.Furthermore,WASHinfrastructureincludingtoiletfacilitiesandcleanwatersourcesarerequiredforabehaviourchangecommunicationstrategytobesuccessfulinpromotinghygienebehaviours.

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ProposedBehaviouralIntervention Basedontheinsightsgainedfromtheformativeresearch,wedevelopedabehaviouralinterventionunderpinnedbytheBehaviourCentredDesignFrameworkandtheoryandtargetedtowardsadolescents.ThefulldetailsoftheinterventionareintheAppendix.Belowisasummary: InterventionName: MyCleanPieceofZed

CalltoAction: Where’sYourPiece?

TargetAudience: Adolescentboysandgirlsagedbetween15and19years

Targetareas(forpilot): 1urbanand1ruralhotspot

Durationofpilot: 18months

DesiredBehaviours: 1. Washhandswithsoapafterfaecalcontactandbeforecontactwithfood

2. Treatdrinkingwaterwithchlorine3. Re-heatcookedfoodbeforeconsumption

Motives: Status(pride),Play,Affiliation

RecruitmentStrategy: SourceandtrainpotentialadolescentCommunityChampionsbasedontheirpropensitytobecommunity-centric.Theywillbeempoweredwithinformationandmotivatedusingsuccessstories,emotionaldemonstrationsandgamestopracticeandencouragethethreebehavioursintheirhomes.Theexpectedbehaviouraloutcomeisthatthethreebehavioursarepracticedattherequiredoccasionsbyallmembersofthehousehold.

EngagementActivities: Debate,socialmediamovement,poetry,broadcastedinterviews,talkingwallsandphotomosaics.

Evaluation: RandomisedControlTrialDesign

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References

1. WorldHealthOrganisation,2019.TheGlobalTaskForceonCholeraControl.[Online]https://www.who.int/cholera/task_force/en/Accessed29December2019.

2. CentralStatisticalOffice(CSO)[Zambia]MoHMZaII:ZambiaDemographicandHealthSurvey2013-14.Rockville,Maryland,USA:CentralStatisticalOffice,MinistryofHealth,andICFInternational2014.

3. AungerR.,etal(2017).BEHAVIOURCENTREDDESIGN:FORMATIVERESEARCHPROTOCOLS.[Online].LSHTM(https://www.lshtm.ac.uk/sites/default/files/2017-03/BCD%20Formative%20Research%20Protocols%20v1.1.pdf)Accessed29December2019.

4. CentralStatisticsOffice,2013.PopulationandDemographicProjections2011–2035.[Online].ZambiaCSO,https://www.zamstats.gov.zm/phocadownload/Zambia%20Census%20Projection%202011%20-%202035.pdf.Accessed28December2019.

5. KabweP,MoondeL,GamaA,HadunkaF,SinyangweN,KateuleE,etal.DescriptivecharacterizationofthecholeraoutbreakInLusakaDistrict,2016.HealthPressZambiaBull.2017;1(2)

6. Aunger,R.,&Curtis,V.(2016).BehaviourCentredDesign:towardsanappliedscienceofbehaviourchange.Healthpsychologyreview,10(4),425–446.doi:10.1080/17437199.2016.1219673

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Appendix