March - April 2016

Nan Lewicky
Alice Payne Merritt
Elli Leontsini
Gabrielle Hunter
Pablo Palacios Naranjo
Publication Date
June 9, 2016

Health Communication Capacity Collaborative (HC3)

"[T]he number of confirmed cases remains minimal, causing rumors and lack of trust towards public health authorities in the local press and social media, as well as the population, and even among practicing clinicians. Trust is an important aspect of SBCC, and risk communication, in particular; understanding the sources of distrust is a key first step to developing a risk communication strategy."

In this report on Zika in four Central American countries - Honduras, El Salvador, Dominican Republic and Guatemala - the Health Communication Capacity Collaborative (HC3) offers recommendations for improving the social and behaviour change communication (SBCC) response to the virus. HC3, which is funded by the United States Agency for International Development (USAID) and based at the Johns Hopkins Center for Communication Programs (CCP), visited the four countries in March and April 2016 to quickly take the pulse of the Zika situation and the local response.

HC3 teams met with stakeholders from the public, non-governmental organisations (NGOs), and private sectors in each country, and this report explores nuances across countries. For example, while the government of each country is taking a lead in the response, transparency of their actions and plans, as well as the regular sharing of local statistics, varies widely. In El Salvador, two government-led coordinating mechanisms meet regularly: (i) an inter-sectoral government meeting that is held weekly, and (ii) a monthly meeting that includes government, NGOs and international and bilateral groups with the wider stakeholders, where there appears to be high technical involvement of partners. In Honduras, on the other hand, the coordination and transparency seemed less developed, with the government calling ad hoc meetings with different partners. However, HC3 learned that, since their visit, more regular collaboration and meetings have taken place through the stakeholder group led by the United Nations Children's Fund (UNICEF).

HC3 determined that all four countries could benefit from technical assistance to develop or refine national Zika communication strategies. HC3 stressed that communication strategies should be developed and implemented with key partners to ensure greater consistency of prevention messages in implementation and community outreach. "The most effective way to ensure that both political and technical stakeholders buy into the strategy and messages is to include them as part of the design process," the report stresses, noting that those stakeholders include: the Ministry of Health; NGOs and others working in SBCC, community mobilisation, and advocacy; university and/or research representatives; and those responsible for family planning (FP) distribution and placement. Each country should consider conducting rapid formative research within communities to better understand the myths and perceptions around Zika and other mosquito-borne diseases. That research should also explore knowledge, attitudes, and perceptions of vector control outreach workers, community mobilisers, and service providers to better incorporate them as both an intended audience and as message disseminators in Zika communication activities.

HC3 found and describes here some challenges related to infrastructure, vector control, laboratories, and FP use and access (especially for specific populations like migrants) during this outbreak, as well as the availability of reproductive health services for pregnant women.

In terms of communication-centric issues, at the time of the landscaping visits, risk perception across all countries was low, due to: (i) acceptance of mosquito-borne diseases as unavoidable; (ii) greater fear of mortality and morbidity of dengue and chikungunya than Zika; (iii) a feeling that it's not worth the effort to go to the clinic as "there's nothing you can do"; and (iv) no personal exposure to microcephaly/Guillain-Barre Syndrome (GBS) as of yet. "For these reasons, it is difficult to change behaviors that have become the norm, even during the countries' prior Aedes [aegypti, the mosquito responsible not only for Zika but also for dengue and chikungunya disease] outbreaks." HC3 found that, despite low risk perception, all countries are attempting to motivate active engagement with campaign slogans encouraging individuals to do their part. General household and cleanup campaigns are promoted by both government and NGO sectors as part of Zika prevention efforts, yet recommended container cleaning behaviours are labour intensive and need to be repeated frequently, which are a burden on the already overworked women who are the primary caregivers. While general cleanup campaigns are positive and promote overall healthy living, they also may lead to less focused messages and a diffused or scattered "call to action". As a result, community mobilisers and individuals can spend a lot of time picking up garbage, which is less likely to be an Aedes breeding site, rather than cleaning large water receptacles which may harbour the most mosquito eggs and larvae. "[T]he behaviors easiest to carry out are those for general garbage clean ups, which tends to be a mistaken focus discussed by authorities and seen on TV spots." Some outreach materials show a menu of actions people should take to clean up their yard to prevent Zika, including things like sweeping away puddles and leaves from backyards, which are not habitats in which the Aedes mosquito would breed in large number. "This is another leverage point where more coordinated and state of the art SBCC might bring positive change."

The report includes descriptions of each country landscape in detail, with specifics about risk communication activities, followed by an offering of a series of recommendations across the countries and specific to each country. Some general recommendations include:

  • "Countries should take advantage of the NGO community that has strong links to peri-urban and rural communities. Many of the NGOs use community participation methodologies that empower communities to be proactive in vector control. Bring on more partners who can widen the reach of this community, such as church networks and the private sector, who benefit from a healthy workforce and play a large role in some countries in the tourist industry."
  • With regard to communication strategies, final documents describing plans should include not only specific communication objectives but also: key messaging (including specific "calls to action" that focus on controlling Aedes breeding sites and messages that are motivational, positioning mosquito-borne illnesses as something not inevitable); guidance on key audiences, channels, and tone (creative briefs); and identification of leadership, responsibilities and distribution of efforts across partners and geographic areas. All four countries would benefit from developing audience-specific materials based on technically sound and global recommendations. Regional guidance documents could be identified or developed for specific SBCC Zika materials or generic and adaptable creative briefs/materials developed for country adaptation. These could include: provider jobs aids (FP and Zika, sexual transmission, prenatal Zika prevention, microcephaly, and GBS prevention and treatment); outreach workers' Aedes breeding site reduction aid; and a press information packet. Systems for regularly updating the press should be in place, as should mechanisms for open, transparent communication for questions and timely exchanges. Internews or a similar organisation could be approached to develop a media training package and workshop, as well as a rumour tracking system as done by HC3 for Ebola.
  • There should be more attention paid to FP messaging to address sexual transmission of Zika. Messaging for pregnant women or those thinking about having children in the near future could be improved and more integrated into counseling and outreach opportunities.
  • Vector control field staff and other NGO outreach workers need to be trained in interpersonal communication (IPC), personal prevention of Zika, chikungunya, dengue, recognition of symptoms, and health care seeking. (In Guatemala, because the operativos (field staff) have more contact with community members than others, they often find themselves in the position of ad hoc communicators about Aedes-transmitted disease prevention, symptom recognition, and other topics. However, they are not trained in counseling or IPC. "Similarly, the language they use is often too technical, hindering the effectiveness in their own interventions to engage households in vector control.")
  • Digital platforms should be explored for improving communication and outreach to pregnant women and women of reproductive age via WhatsApp or along the lines of the txt4baby platform. This falls into the context of the SMART client approach, where interventions empower women to answer the questions they might already have, think about what else they need to make decisions, and get access to resources to address their needs (informational and/or FP services). The platform would need to be promoted, presumably through existing relevant mechanisms. Digital platforms can also support providers in FP counseling and Zika prevention during pregnancy. WhatsApp groups could be organised for providers with Zika frequently asked questions (FAQs) as a job aid. An online portal and regional network should be developed to serve as a neutral platform for Zika stakeholders to share SBCC materials. (Note: USAID has subsequently approved funding for this activity.)
  • Communication and mobilisation activities should include monitoring and evaluation (M&E) that measures not only process indicators (e.g., materials produced and houses visited) but also impact indicators (household larval indices), if at all possible.

"HC3 Report Evaluates SBCC Response to Zika in Four Latin American Countries", by Kim Martin, July 25 2016 - accessed on July 29 2016.