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Summary report: Lessons from previous outbreaks that can inform WASH/public health programming
Summary report: Lessons from previous outbreaks that can inform WASH/public health programming
Sian White avatar
Written by Sian White
Updated over a week ago

Outbreaks are not new. There are plenty of lessons that can be learned from looking at prior outbreaks of diseases like cholera, Ebola and SARS. Below we explore six key lessons.

1. Coordination is critical 

During any outbreak, coordination at all levels between responding agencies and across sectors  is essential. When this is lacking, critical aspects of prevention, testing and treatment can become delayed, resources may be poorly used due to replication of efforts, and populations can be confused by public health messaging. For example, different and conflicting messages undermined the response in the Haiti cholera response. 

During outbreaks, it is important that all work is coordinated and aligned with national government guidelines and strategies. When outbreaks occur, the WHO develops coordination guidelines based on prior outbreak experience. For instance, during the COVID-19 pandemic, the WHO produced guidelines which provide a roadmap for country-level coordination and identify processes for each pillar of COVID-19 response, including risk communication and community engagement; surveillance, rapid response teams, and case investigation; infection prevention and control; case management; operational support and logistics, among others. 

However, there is a risk that coordination is sometimes understood to be the same as standardisation. One of the common criticisms of humanitarian responses is that we typically see standardised interventions being implemented with relatively little context adaptation. Indeed, in the West African Ebola outbreak, standardized nation-wide messages curtailed the ability for organisations to adopt innovative or context-adapted responses. This meant that populations in many regions of the country disengaged with the public health messaging because it seemed to lack relevance to them.  

2. An enabling environment is key 

Giving behaviour change messages without providing the necessary hardware, such as soap and water, and a conducive enabling environment, will leave people feeling frustrated and unable to adhere to guidelines. It is important to provide hardware and infrastructural improvements where needed, but at the same time, understanding the psychological and social determinants of behaviour should not be deprioritised. The quote below comes from a man residing in a displacement camp in the Democratic Republic of Congo (DRC). He expresses his frustrations about organisations involved in running hygiene promotion in the region during a cholera outbreak.  

“I can tell you that I had a good life. I was rich. But everything changed when I was displaced. Now everything is bad. You cannot blame me if I don’t always wash my hands. Give me back my previous life and you would see how my emotions and life would change - then there will be a high chance I will wash my hands with soap.  It is good that organizations don’t forget us but you come now that there is cholera and just talk about handwashing. We know what we should do but we don’t have soap or water here and we are living like animals.”

3. Don’t forget that handwashing is always driven by a range of determinants

A systematic review of handwashing determinants found that during outbreaks, there is a tendency to target behaviour change programmes at a narrow range of determinants. For example, research undertaken during outbreaks predominantly focuses on understanding fear and risk perception. However, responders during the West African Ebola outbreak reflected that this was a missed opportunity and that more could have been done to actively understand what was driving behaviour and to ensure that programmes were adapted to the local context in each region. Given the speed of the spread of infectious disease outbreaks, such as COVID-19 and Ebola, it is recommended that in the first phase of the response you undertake simple actions that are vital for controlling transmission (see ‘Practical actions to promote handwashing during the 1st phase of COVID-19 response’). During this stage you can also set up mechanisms to learn from your community, identify needs and adapt your programming accordingly. See our resource on conducting remote community engagement for further guidance.

4. Engender trust

Trust of responders is key to adherence - communication and engagement of the community builds trust of the responders. Using locally known and trusted messengers will increase acceptance and adherence. Both in the Ebola response and in the Polio eradication program, initiatives were found to have the greatest effect when led by local leaders. The group of people listed as most important to involve, were religious leaders, followed by traditional leaders, other local authorities or leaders, and women or women’s groups. You can find the WHO outbreak communication guidelines here.

5. Messages should be clear and actionable 

During an outbreak, people can feel panicked and overwhelmed with all the information that they are receiving from many different channels. Make sure health and behavioural messages are clear, simple and easy to understand. For example, the image below was pictured in a refugee camp where diarrhoeal outbreaks are common. The billboard message is not clear, because it does not tell people which hygiene behaviour to practice. It is also not easy to understand, because it is written in English when this was not the language spoken by the population. In fact lots of people in this area had limited literacy, so using images would have been important to enhance understanding in this context.

Source: London School of Hygiene and Tropical Medicine

Simple messaging doesn’t have to be dull. For instance, this COVID-19 video conveys a simple behaviour (handwashing with soap) through a compelling story.

6. The disease outbreak is not the only challenge people are facing

During outbreaks, news headlines are often largely dominated by stories about the focal disease. Depending on the scale of the outbreak, the response will typically be well resourced and will continue for many months. But we have to remember that the outbreak is not the only problem for many people. Globally, populations face multifaceted crises, including conflict, natural disasters, food and socioeconomic crises, which may take precedent in some cases.

The quote below is taken from an article on Ebola in DRC. The article was written by MSF, and highlights that short-sighted and narrowly-focused outbreak responses are often misaligned to real community needs.

“My husband was killed in a massacre in Beni. At that time, all I wanted was some organization to come protect us from the killings, but no international organization came. I have had three children die of malaria. No international organization has ever come to work in this area to make sure we have access to health care or clean water. But now Ebola arrives, and all the organizations come because Ebola gives them money. If you cared about us, you would ask us our priorities. My priority is security and making sure my children don't die from malaria or diarrhea. My priority is not Ebola. That is your priority.”

Ignoring other problems poses several risks. Firstly, it can result in interventions being poorly accepted by the local population and secondly it can have severe consequences for other critical health services, due to them not being sufficiently resourced or utilised by the public. For instance, the COVID-19 crisis has had a profound effect on people’s livelihoods and food security. Keeping this in mind and linking your work to ongoing initiatives can be key for ensuring your programme will be able to effectively meet all of the needs of your target population. The WHO have published this for maintaining health systems delivery of essential health services.

Editor's note

Author: Sian White
Reviewer: Julie Watson, Caroline Favas
Last update: 06.05.2020 

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