Coronavirus and the disease it causes, COVID-19, is creating an unprecedented global health emergency. Infection rates across most countries in the world are following a similar trajectory with real risks of overwhelming health services, high morbidity and mortality rates and real disruption to economies. In countries in East Africa, where infection numbers are relatively small at this point, we are at a crucial stage of preventing new infections and curbing the spread.
This presents questions about how prepared we are and where the emphasis should be placed?
Working with low income communities in the region, we understand the likely impact of the pandemic on the urban poor. Urban slums remain hotspots for the spread of disease. These settlements are characterized by high population density/overcrowded spaces, reliance on daily wages or earnings and poor hygiene practices, including the preparation and sale of food in open areas. These, coupled with inadequate hand washing facilities in social/public places and inadequate hygiene messaging may exacerbate the spread of the virus.
By necessity, our immediate response is to focus on increasing access to clean and safe water, increasing access to soap and hygiene products and ensuring that we limit virus transmission in common spaces. As an organization, we have the experience and capabilities to this, especially through delegated water management systems developed in urban settlements and local distribution networks for hand washing facilities and soap.
However, my own reflection on previous epidemic responses, such as Ebola and learning from years of WASH programming in Kenya, is that while awareness of the importance of hand-washing at critical times in the country remains high, why is the practice of good hygiene still so low?
A study in 2009 found that despite very high levels of awareness, only 14% of primary care givers in urban low income areas washed hands at critical moments, and only 5% consistently used soap. A number of practical and other issues proved to be real barriers to translating good intentions into consistent actions. These included the type of facilities, accessibility and of course prioritization of water use in the home and shared facilities. But the simple truth remains that it is still just not a habit or a desirable thing to do.
All the above factors considered, could the answer be an even greater focus on behaviour change and establishing a new social norm around handwashing? And should this be the main focus of the COVID 19 prevention and response plan by many countries at the onset of the spread?
I believe an investment in relevant behaviour change communication (BCC) is needed. BCC that responds to the needs of low income communities and that communicate simplified messaging on hygiene. We would also need investments in how effective communication is managed and invest in new channels of communication that use and encourage social distancing, such as using media channels, murals and/ or community messaging boards. This would, of course, change the spread of other infectious diseases as well, reflecting on the recent breakthrough in our own work that has reduced cases of waterborne diseases in children under 5 over the past year by 5%!
Most importantly, ensuring that messaging and communication is inclusive, understanding the different needs of men, women and children, and in this case, people most at risk from the virus – and including skills development that could entice more and more of us to wash our hands.
Designing, developing and piloting ‘do-it-yourself’ training manuals for use by community members is an innovation we are pretty proud and that has been received very well by the communities we work with. This includes training manuals on water safety and behaviour change, personal hygiene and soap production that would all be crucial in this stage of preventing the spread.